Article

Assessment of isometricity before and after total knee arthroplasty: A cadaver study

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Abstract

Total knee arthroplasty (TKA) relies on soft tissue to regulate joint stability after surgery. In practice, the exact balance of the gaps can be difficult to measure, and various methods including intra-operative spreaders or distraction devices have been proposed. While individual ligament strain patterns have been measured, no data exist on the isometricity of the soft tissue envelope as a whole. In this study, a novel device was developed and validated to compare isometricity in the entire soft tissue envelope for both the intact and TKA knee. A spring-loaded rod was inserted in six cadaver knee joints between the tibial shaft and the tibial plateau or tibial tray after removing a 7 mm slice of bone. The displacement of the rod during passive flexion represented variation in tissue tension around the joint. The rod position in the intact knee remained within 1 mm of its initial position between 15 degrees and 135 degrees of flexion, and within 2 mm (+/-1.2 mm) throughout the entire range of motion (0-150 degrees). After insertion of a mobile-bearing TKA, the rod was displaced a mean of 6 mm at 150 degrees (p<0.001). The results were validated using a force transducer implanted in the tibial baseplate of the TKA, which showed increased tibiofemoral force in the parts of the flexion range where the rod was most displaced. The force measurements were highly correlated with the displacement pattern of the spring-loaded rod (r=-0.338; p=0.006). A simple device has been validated to measure isometricity in the soft tissue envelope around the knee joint. Isometricity measurements may be used in the future to improve implantation techniques during TKA surgery.

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... It has been suggested to use the ''intact knee'' data as a reference for the behaviour of the soft tissues, and while performing TKA, to aim for a laxity that is within the range of a non-arthritic native knee [5,16,17]. Therefore, we stress that, during TKA surgery, it is important to attempt to preserve the ligaments, which are acting almost isometrically, as much as possible. However, it is obvious that insertion of a TKA with different material properties and surface geometry, compared to the native knee has implications on the mechanical stress of the surrounding soft tissue envelope. ...
... Two extensometers (MTS, Eden Prairie, Minnesota, USA) were firmly sutured to the lateral and medial superficial collateral ligaments centred over the joint line, with the knee unloaded and in full extension. Procedures described by Kuster [17], were used, as well as the anatomic description of Espregueira-Mendes for the LCL [8] and La Prade for the MCL [18] (Fig. 1). The fixation technique of the extensometers was preliminary tested by manually squeezing the measurement arms and let them spring back to their original position, while the ligament was left in its unstrained position. ...
... Nevertheless, the strains remained always somewhat higher than in the native situation. Kuster [17] and Van Damme [22] previously noted this phenomenon and suggested that the alteration in soft tissue behaviour was caused by changes in the articulating surface configuration from native human to prosthetic. ...
Article
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Currently, controversy exists whether restoration of neutral mechanical alignment should be attempted in all patients undergoing TKA. Our hypothesis was that restoration of constitutional rather than neutral mechanical alignment may in theory lead to a more physiological strain pattern in the collateral ligaments; therefore, it could potentially be beneficial to patients. Thus, the aim of this study was to measure collateral ligament strains during three motor tasks in the native knee and compare them with the strains noted after TKA in different post-operative alignment conditions. Six cadaver specimens (approval number ML4190 from the Research Ethics Committee of University of Leuven, Belgium) were examined using a validated knee kinematics rig under physiological loading conditions. The effect of coronal malalignment was evaluated by using custom-made tibial implant inserts that induced different alignment conditions. The study of six specimens allows us to show that a difference in the mean strains in MCL and LCL of 3.6 and 5.8 %, respectively, was statistically significant with a probability (power) of 0.8. The results indicated that after TKA insertion, the strains in the collateral ligaments closely resembled the pre-operative pattern of the native knee specimens when constitutional alignment was restored. Restoration to neutral mechanical alignment was associated with greater collateral strain deviations from the native knee. Based upon this study, it was concluded that restoration of constitutional alignment within a "safe zone" of ±2° during TKA leads to more physiological peri-articular soft tissue strains during loaded as well as unloaded motor tasks.
... From a biomechanical perspective, joint line elevation will first of all change the positions of the insertion regions of the collateral ligaments with respect to the flexion axes of the knee. As such, it will lead to deviations from the generally isometric behavior of the collateral ligaments [18,19], but in a more complex way than simply loosening or tightening them. The effect on collateral ligament length will be dependent on the flexion angle. ...
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Correct restoration of the joint line is generally considered as crucial when performing total knee arthroplasty (TKA). During revision knee arthroplasty however, elevation of the joint line occurs frequently. The general belief is that this negatively affects the clinical outcome, but the reasons are still not well understood. In this cadaveric in vitro study the biomechanical consequences of joint line elevation were investigated using a previously validated cadaver model simulating active deep knee squats and passive flexion-extension cycles. Knee specimens were sequentially tested after total knee arthroplasty with joint line restoration and after 4 mm joint line elevation. The tibia rotated internally with increasing knee flexion during both passive and squatting motion (range: 17° and 7° respectively). Joint line elevation of 4 mm did not make a statistically significant difference. During passive motion, the tibia tended to become slightly more adducted with increasing knee flexion (range: 2°), while it went into slighlty less adduction during squatting (range: -2°). Neither of both trends was influenced by joint line elevation. Also anteroposterior translation of the femoral condyle centres was not affected by joint line elevation, although there was a tendency for a small posterior shift (of about 3 mm) during squatting after joint line elevation. In terms of kinetics, ligaments lengths and length changes, tibiofemoral contact pressures and quadriceps forces all showed the same patterns before and joint line elevation. No statistically significant changes could be detected. Our study suggests that joint line elevation by 4 mm in revision total knee arthroplasty does not cause significant kinematic and kinetic differences during passive flexion/extension movement and squatting in the tibio-femoral joint, nor does it affect the elongation patterns of collateral ligaments. Therefore, clinical problems after joint line elevation are probably situated in the patello-femoral joint or caused by joint line elevation of more than 4 mm.
... Positive correlation exists between the HKA, and maximal varus stress obtained intraoperatively (r = 0.75, instability, the second most common cause of failure after infection [1,2,8]. The medial and lateral collateral ligaments have been shown to be nearly isometric between 0° and 120° of flexion as Victor [4,5,11]. Osteoarthritic ligaments are stiffer with less elongation compared with normal knees; however, the medial collateral ligament demonstrates a linear load-elongation response, and some authors have failed to demonstrate a progressive shortening of the medial collateral ligament in deformities <10° of varus [7,8]. ...
Article
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The aim of this study was to test the hypothesis that the coupled features of passive knee flexion are guided by articular contact and by the isometric fascicles of the ACL, PCL and MCL. A three-dimensional mathematical model of the knee was developed, in which the articular surfaces in the lateral and medial compartments and the isometric fascicles in the ACL, PCL and MCL were represented as five constraints in a one degree-of-freedom parallel spatial mechanism. Mechanism analysis techniques were used to predict the path of motion of the tibia relative to the femur. Using a set of anatomical parameters obtained from a cadaver specimen, the model predicts coupled internal rotation and ab/adduction with flexion. These predictions correspond well to measurements of the cadaver specimen's motion. The model also predicts posterior translation of contact on the tibia with flexion. Although this is a well-known feature of passive knee flexion, the model predicts more translation than has been reported from experiments in the literature. Modelling of uncertainty in the anatomical parameters demonstrated that the discrepancy between theoretical predictions and experimental measurement can be attributed to parameter sensitivity of the model. This study shows that the ligaments and articular surfaces work together to guide passive knee motion. A principal implication of the work is that both articular surface geometry and ligament geometry must be preserved or replicated by surgical reconstruction and replacement procedures to ensure normal knee kinematics and by extension, mechanics.
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Stiffness of the medial (MCL) and lateral (LCL) collateral ligaments was compared between a group of 10 patients undergoing total knee arthroplasty for varus degenerative osteoarthritis (OAP), a group of 10 osteoarthritic cadaveric knees (OAC), and a group of 10 non-osteoarthritic cadaveric knees (NOA). A load-elongation curve was obtained for the medial and lateral compartments of each knee using an instrumented Moreland spreader. A strain gage (SG) was attached to the spreader handle and strain was calibrated to load applied against the spread distance. In extension, medial compartment stiffness of the OAP, OAC, and NOA groups was 60.7+/-16, 52.8+/-9.3 and 21.4+/-5.0 N/mm, respectively. Lateral compartment stiffness in extension was 29.2+/-9.2, 33.3+/-10.3 and 19.5+/-5.3 N/mm, for OAP, OAC, and NOA, respectively. Differences in stiffness between the OAP and OAC groups were not statistically significant (p > 0.05). However, the osteoarthritic groups (OAP and OAC) demonstrated a statistically significantly (p < 0.05) increase in ligament stiffness when compared to the NOA group. Following knee arthroplasty, stiffer medial structures in extension may lead to flexion contracture and accelerated polyethylene wear. Adequate bone resection, in conjunction with soft tissue release may alleviate the threefold increase in stiffness observed in the medial compartment secondary to OA without jeopardizing joint stability.
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Tibial forces are important because they determine polyethylene wear, stress distribution in the implant, and stress transfer to underlying bone. Theoretic estimates of tibiofemoral forces have varied between three and six times the body weight depending on the mathematical models used and the type of activity analyzed. An implantable telemetry system was therefore developed to directly measure tibiofemoral compressive forces. This system was tested in a cadaver knee in a dynamic knee rig. A total knee tibial arthroplasty prosthesis was instrumented with four force transducers located at the four corners of the tibial tray. These transducers measured the total compressive forces on the tibial tray and the location of the center of pressure. A microprocessor performed analog-to-digital signal conversion and performed pulse code modulation of a surface acoustic wave radio frequency oscillator. This signal was then transmitted through a single pin hermetic feed-through tantalum wire antenna located at the tip of the stem. The radio frequency signal was received by an external antenna connected to a receiver and to a computer for data acquisition. The prosthesis was powered by external coil induction. The tibial transducer accurately measured both the magnitude and the location of precisely applied external loads. Successful transmission of the radio frequency signal up to a range of 3m was achieved through cadaveric bone, bone cement, and soft tissue. Reasonable accuracy was obtained in measuring loads applied through a polyethylene insert. The implant was also able to detect unicondylar loading with liftoff.
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Retrospective review of 1216 primary total knee arthroplasties (TKAs) to evaluate incidence and predictors of arthrofibrosis, defined as flexion less than 90 degrees 1 year post-TKA. Incidence of stiffness post-TKA was 3.7% (45/1216). A matched case-control study was then conducted to identify predictive factors for this outcome. Preoperative flexion and intraoperative flexion were predictive of ultimate postoperative flexion (P = .001 and P = .039, respectively). There was no correlation between postoperative stiffness and specific medical comorbidities, including diabetes. Preoperative and postoperative relative decreased patellar height and stiffness postoperative were significantly correlated (P = .001). Although stiffness post-TKA is multifactorial, careful attention to surgical exposure, restoring gap kinematics, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, and physiotherapy combined with a well-motivated patient may all serve to reduce the incidence of stiffness post-TKA.
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Despite ongoing evolution in total knee arthroplasty (TKA) prosthesis design, restricted flexion continues to be common postoperatively. Compressive tibiofemoral force during flexion is generated through the interaction between soft tissues and prosthesis geometry. In this study, we compared the compressive tibiofemoral force in vitro of four commonly used prostheses: fixed-bearing PCL (posterior cruciate ligament)-retaining (PFC), mobile-bearing posterior-stabilized (PS), posterior-stabilized with a High Flex femoral component (HF), and mobile-bearing PCL-sacrificing (LCS). Fourteen fresh-frozen cadaver knee joints were tested in a passive motion rig, and tibiofemoral force measured using a modified tibial baseplate instrumented with six load cells. The implants without posterior stabilization displayed an exponential increase in force after 90° of flexion, while PS implants maintained low force throughout the range of motion. The fixed-bearing PFC prosthesis displayed the highest peak force (214 ± 68 N at 150° flexion). Sacrifice of the PCL decreased the peak force to a level comparable with the LCS implant. The use of a PCL-substituting post and cam system reduced the peak force up to 78%, irrespective of whether it was a high-flex or a standard PS knee. However, other factors such as preoperative range of motion, knee joint kinematics, soft tissue impingement, and implantation technique play a role in postoperative knee function. The present study suggests that a posterior-stabilized TKA design might be advantageous in reducing soft tissue tension in deep flexion. Further research is necessary to fully understand all factors affecting knee flexion after TKA. © 2007 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
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