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Sexual and ethnic polymorphism render prosthetic overhang and under-coverage inevitable using off-the shelf TKA implants

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Unexplained pain and stiffness after total knee arthroplasty (TKA) often result from mismatch between implant geometry and knee morphology, which depends on patient size, sex, and ethnicity. This study aimed to determine whether size, sex, or ethnicity are independently associated with distal femoral morphology in healthy Caucasian and Asian knees, and to compare anatomic ratios to those of commercially available TKA implants.

Methods

Two series of computed tomography (CT) angiograms from France (264 knees) and China (259 knees) were used to digitize osteometric landmarks at the level of the femoral epicondyles, to measure anteroposterior (AP) and mediolateral (ML) dimensions at the anterior, posterior, medial, and lateral zones. The aspect (ML/AP), trapezoidicity (MLp/MLa), and asymmetry (APl/APm) ratios, as well as the sulcus angle were calculated and compared to those of 9 TKA models. Multivariable analyses were performed to determine whether anatomic ratios were independently associated with sex, origin, or size.

Results

Multivariable analyses revealed that, independently from size, female knees were narrower (β = − 0.03; p < 0.001) and more asymmetric (β = 0.02; p < 0.001), while Chinese knees were more trapezoidal (β = 0.04; p = 0.002) and asymmetric (β = 0.02; p < 0.001) with shallower trochleae (β = 6.4°; p < 0.001). Compared to native knees, most implants were too wide, and many of the recent models too ‘trapezoidal’. Most prosthetic trochleae were too shallow compared to French knees, but within the third quartile of Chinese knees.

Conclusions

The morphology of the distal femur depends on sex and ethnicity independently from size. The wide spectrum of morphotypes observed cannot be covered by ‘off-the-shelf’ TKA models, and until customized implants become more accessible, prosthetic overhang, and under-coverage remain inevitable.

Level of evidence

III, Retrospective comparative study.

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References

  1. Austin PC, Steyerberg EW (2015) The number of subjects per variable required in linear regression analyses. J Clin Epidemiol 68(6):627–636

    Article  PubMed  Google Scholar 

  2. Bellemans J, Carpentier K, Vandenneucker H, Vanlauwe J, Victor J (2010) The John Insall Award: both morphotype and gender influence the shape of the knee in patients undergoing TKA. Clin Orthop Relat Res 468(1):29–36

    Article  PubMed  Google Scholar 

  3. Bonnin MP, de Kok A, Verstraete M, Van Hoof T, Van Der Straten C, Saffarini M, Victor J (2017) Popliteus impingement after TKA may occur with well-sized prostheses. Knee Surg Sports Traumatol Arthrosc 25(6):1720–1730

    Article  PubMed  Google Scholar 

  4. Bonnin MP, Saffarini M, Bossard N, Dantony E, Victor J (2016) Morphometric analysis of the distal femur in total knee arthroplasty and native knees. Bone Joint J 98-b (1):49–57

  5. Bonnin MP, Saffarini M, Mercier PE, Laurent JR, Carrillon Y (2011) Is the anterior tibial tuberosity a reliable rotational landmark for the tibial component in total knee arthroplasty? J Arthroplast 26(2):260–267.e261-262

    Article  Google Scholar 

  6. Bonnin MP, Saffarini M, Shepherd D, Bossard N, Dantony E (2016) Oversizing the tibial component in TKAs: incidence, consequences and risk factors. Knee Surg Sports Traumatol Arthrosc 24(8):2532–2540

    Article  PubMed  Google Scholar 

  7. Bonnin MP, Schmidt A, Basiglini L, Bossard N, Dantony E (2013) Mediolateral oversizing influences pain, function, and flexion after TKA. Knee Surg Sports Traumatol Arthrosc 21(10):2314–2324

    Article  PubMed  PubMed Central  Google Scholar 

  8. Brattstroem H (1964) Shape of the intercondylar groove normally and in recurrent dislocation of patella. A clinical and X-ray-anatomical investigation. Acta Orthop Scand 68:SUPPL 68:1–148

    Article  Google Scholar 

  9. Cavaignac E, Li K, Faruch M, Savall F, Chiron P, Huang W, Telmon N (2017) Three-dimensional geometric morphometric analysis reveals ethnic dimorphism in the shape of the femur. J Exp Orthop 4(1):13

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cavaignac E, Savall F, Faruch M, Reina N, Chiron P, Telmon N (2016) Geometric morphometric analysis reveals sexual dimorphism in the distal femur. Forensic Sci Int 259:246.e241–246.e245

    Article  Google Scholar 

  11. Cheng T, Zhu C, Wang J, Cheng M, Peng X, Wang Q, Zhang X (2014) No clinical benefit of gender-specific total knee arthroplasty. Acta Orthop 85(4):415–421

    Article  PubMed  PubMed Central  Google Scholar 

  12. Clarke HD, Hentz JG (2008) Restoration of femoral anatomy in TKA with unisex and gender-specific components. Clin Orthop Relat Res 466(11):2711–2716

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dai Y, Scuderi GR, Penninger C, Bischoff JE, Rosenberg A (2014) Increased shape and size offerings of femoral components improve fit during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22(12):2931–2940

    Article  PubMed  PubMed Central  Google Scholar 

  14. Dejour D, Ntagiopoulos PG, Saffarini M (2014) Evidence of trochlear dysplasia in femoral component designs. Knee Surg Sports Traumatol Arthrosc 22(11):2599–2607

    Article  PubMed  Google Scholar 

  15. Gibon E, Goodman MJ, Goodman SB (2017) Patient satisfaction after total knee arthroplasty: a realistic or imaginary goal? Orthop Clin North Am 48(4):421–431

    Article  PubMed  Google Scholar 

  16. Gunaratne R, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW (2017) Patient dissatisfaction following total knee arthroplasty: a systematic review of the literature. J Arthroplast 32(12):3854–3860

    Article  Google Scholar 

  17. Hitt K, Shurman JR, Greene K, McCarthy J, Moskal J, Hoeman T, Mont MA (2003) Anthropometric measurements of the human knee: correlation to the sizing of current knee arthroplasty systems. J Bone Joint Surg Am 85-A(Suppl 4):115–122

    Article  Google Scholar 

  18. Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML (2013) Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res 471(3):1000–1007

    Article  PubMed  Google Scholar 

  19. Ishimaru M, Hino K, Onishi Y, Iseki Y, Mashima N, Miura H (2014) A three-dimensional computed tomography study of distal femoral morphology in Japanese patients: gender differences and component fit. Knee 21(6):1221–1224

    Article  PubMed  Google Scholar 

  20. Kawahara S, Matsuda S, Fukagawa S, Mitsuyasu H, Nakahara H, Higaki H, Shimoto T, Iwamoto Y (2012) Upsizing the femoral component increases patellofemoral contact force in total knee replacement. J Bone Joint Surg Br 94(1):56–61

    Article  CAS  PubMed  Google Scholar 

  21. Kim JB, Lyu SJ, Kang HW (2016) Are Western Knee designs dimensionally correct for korean women? A morphometric study of resected femoral surfaces during primary total knee arthroplasty. Clin Orthop Surg 8(3):254–261

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Kim TK, Phillips M, Bhandari M, Watson J, Malhotra R (2017) What differences in morphologic features of the knee exist among patients of various races? A systematic review. Clin Orthop Relat Res 475(1):170–182

    Article  CAS  PubMed  Google Scholar 

  23. Le DH, Goodman SB, Maloney WJ, Huddleston JI (2014) Current modes of failure in TKA: infection, instability, and stiffness predominate. Clin Orthop Relat Res 472(7):2197–2200

    Article  PubMed  PubMed Central  Google Scholar 

  24. Li K, Cavaignac E, Xu W, Cheng Q, Telmon N, Huang W (2018) Morphometric evaluation of the knee in Chinese population reveals sexual dimorphism and age-related differences. Int Orthop 42(10):2349–2356

    Article  PubMed  Google Scholar 

  25. Li P, Tsai TY, Li JS, Zhang Y, Kwon YM, Rubash HE, Li G (2014) Morphological measurement of the knee: race and sex effects. Acta Orthop Belg 80(2):260–268

    PubMed  Google Scholar 

  26. Lombardi AV Jr, Berend KR, Adams JB (2014) Why knee replacements fail in 2013: patient, surgeon, or implant? Bone Joint J 96-b(11 Supple A):101–104

    Google Scholar 

  27. Ma QL, Lipman JD, Cheng CK, Wang XN, Zhang YY, You B (2017) A comparison between chinese and caucasian 3-dimensional bony morphometry in presimulated and postsimulated osteotomy for total knee arthroplasty. J Arthroplast 32(9):2878–2886

    Article  Google Scholar 

  28. Mahfouz M, Abdel Fatah EE, Bowers LS, Scuderi G (2012) Three-dimensional morphology of the knee reveals ethnic differences. Clin Orthop Relat Res 470(1):172–185

    Article  PubMed  Google Scholar 

  29. Mahoney OM, Kinsey T (2010) Overhang of the femoral component in total knee arthroplasty: risk factors and clinical consequences. J Bone Joint Surg Am 92(5):1115–1121

    Article  PubMed  Google Scholar 

  30. Marmor S, Renault E, Valluy J, Saffarini M (2018) Over-voluming predicted by pre-operative planning in 24% of total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-4998-z

    Article  PubMed  Google Scholar 

  31. Merchant AC, Mercer RL, Jacobsen RH, Cool CR (1974) Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am 56(7):1391–1396

    Article  CAS  PubMed  Google Scholar 

  32. Mihalko W, Fishkin Z, Krackow K (2006) Patellofemoral overstuff and its relationship to flexion after total knee arthroplasty. Clin Orthop Relat Res 449:283–287

    Article  PubMed  Google Scholar 

  33. Moghtadaei M, Moghimi J, Shahhoseini G (2016) Distal femur morphology of Iranian population and correlation with current prostheses. Iran Red Crescent Med J 18(2):e21818

    Article  PubMed  PubMed Central  Google Scholar 

  34. Pinskerova V, Nemec K, Landor I (2014) Gender differences in the morphology of the trochlea and the distal femur. Knee Surg Sports Traumatol Arthrosc 22(10):2342–2349

    Article  CAS  PubMed  Google Scholar 

  35. Saffarini M, Demey G, Nover L, Dejour D (2016) Evolution of trochlear compartment geometry in total knee arthroplasty. Ann Transl Med 4(1):7

    PubMed  PubMed Central  Google Scholar 

  36. Singh H, Mittal V, Nadkarni B, Agarwal S, Gulati D (2012) Gender-specific high-flexion knee prosthesis in Indian women: a prospective randomised study. J Orthop Surg (Hong Kong) 20(2):153–156

    Article  CAS  Google Scholar 

  37. Singh JA, Gabriel S, Lewallen D (2008) The impact of gender, age, and preoperative pain severity on pain after TKA. Clin Orthop Relat Res 466(11):2717–2723

    Article  PubMed  PubMed Central  Google Scholar 

  38. von Cramon-Taubadel N, Frazier BC, Lahr MM (2007) The problem of assessing landmark error in geometric morphometrics: theory, methods, and modifications. Am J Phys Anthropol 134(1):24–35

    Article  Google Scholar 

  39. Yue B, Varadarajan KM, Ai S, Tang T, Rubash HE, Li G (2011) Differences of knee anthropometry between Chinese and white men and women. J Arthroplast 26(1):124–130

    Article  Google Scholar 

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Funding

MS and JV received funding for statistical analysis and manuscript preparation from Smith & Nephew.

Author information

Authors and Affiliations

  1. The First Affiliated Hospital of Chongqing Medical University, Chongqing, China

    Ke Li

  2. ReSurg SA, Chemin de Vuarpilliere 35, 1260, Nyon, Switzerland

    Mo Saffarini & Jeremy Valluy

  3. Imascap SAS, Plouzané, France

    Marie-Charlotte Desseroit & Yannick Morvan

  4. Laboratoire AMIS, UMR 5288 CNRS, Université Paul Sabatier, Toulouse, France

    Norbert Telmon & Etienne Cavaignac

  5. Musculoskeletal Institute, Hôpital Pierre Paul Riquet, CHU Toulouse, France

    Etienne Cavaignac

Authors
  1. Ke Li
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  2. Mo Saffarini
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  3. Jeremy Valluy
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  4. Marie-Charlotte Desseroit
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  5. Yannick Morvan
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  6. Norbert Telmon
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  7. Etienne Cavaignac
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Contributions

KL participated in study design, data collection and analysis, and manuscript editing. MS participated in study design, data collection and analysis, literature review, and manuscript writing. JV participated in data analysis and interpretation, tables’ preparation, literature review, and manuscript writing. MCD participated in data collection and analysis and manuscript editing. YM participated in data collection and analysis and manuscript editing. NT participated in study design, data collection and analysis, and manuscript editing. EC participated in study conception and design, data collection and analysis, literature review, and manuscript writing. All authors approved the final manuscript.

Corresponding author

Correspondence to Mo Saffarini.

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Conflict of interest

MCD and YM are employed by Imascap SAS. All the other authors declare that they have no competing interests.

Ethical approval

All patients had provided informed consent for the use of their data and images for study and publication purposes and institutional review board (IRB) approvals were obtained from both healthcare facilities for the use of the existing data and images (Nos. 01-0415 and 01-0416).

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Li, K., Saffarini, M., Valluy, J. et al. Sexual and ethnic polymorphism render prosthetic overhang and under-coverage inevitable using off-the shelf TKA implants. Knee Surg Sports Traumatol Arthrosc 27, 2130–2139 (2019). https://doi.org/10.1007/s00167-019-05410-9

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  • DOI: https://doi.org/10.1007/s00167-019-05410-9

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