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Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 22, Issue 8, pp 1736–1743 | Cite as

Can we define envelope of laxity during navigated knee arthroplasty?

  • K. M. Ghosh
  • A. P. Blain
  • L. Longstaff
  • S. Rushton
  • A. A. Amis
  • D. J. Deehan
Knee

Abstract

Purpose

Functional outcomes after knee arthroplasty (TKA) remain poor. The ability to restore the soft tissue envelope intraoperatively may improve such outcomes. The aim of this study was to extend the scope of computer navigation as a tool to quantifying the envelope of laxity during subjective stress testing preoperatively and to quantify the effects of knee replacement and how it changes as a result of ligamentous failure.

Methods

Loaded cadaveric legs were mounted on a purpose-built rig. Envelope of laxity was measured in 3 degrees of freedom using computer navigation. Knees were subjectively stressed in varus/valgus, internal/external rotation and anterior draw. This was performed preoperatively, during TKA and after sequential sectioning of ligaments. Real-time data were recorded at 0°, 30°, 60° and 90° of flexion. Mixed effect modelling was used to quantify the effects of intervention on degree of laxity.

Results

In all cases, there was an increase in laxity with increasing flexion or ligament sectioning. Operator and movement cycle had no effect. Insertion of a TKA showed increased stability within the joint, especially in internal/external rotation and anterior drawer. Once the PCL and popliteus were cut, the implant only maintained some rotatory stability; thereafter, the soft tissue envelope failed.

Conclusions

This work has shown a novel way by which computer navigation can be used to analyse soft tissue behaviour during TKA beyond the coronal plane and throughout range of motion. Despite subjective stress testing, our results show reproducible patterns of soft tissue behaviour—in particular a wide range of mid-flexion excursion. It also quantifies the limits within which a cruciate-retaining TKR can maintain knee stability. This functionality may guide the surgeon in identifying and/or preventing soft tissue imbalances intra-operatively, improving functional results.

Keywords

Kinematics TKA Soft tissue Cadaveric study Envelope of laxity 

Notes

Acknowledgments

This project was supported and undertaken at the Newcastle Surgical Training Centre (Freeman Hospital, Newcastle Upon Tyne, UK). The authors declare no financial arrangements with the fund holding company.

References

  1. 1.
    Agletti P, Buzzi R, Gauderizi A (1998) Patellofemoral functional results and complications with posterior stabilised total knee prosthesis. J Arthroplasty 3:17–25CrossRefGoogle Scholar
  2. 2.
    Andrews JG (1987) The functional roles of the hamstrings and quadriceps during cycling: Lombard’s paradox revisited. J Biomech 20:565–575PubMedCrossRefGoogle Scholar
  3. 3.
    Blankevoort L, Huiskes R, De Lange A (1998) The envelope of passive knee joint motion. J Biomech 21:705–720CrossRefGoogle Scholar
  4. 4.
    Bull AMJ, Kessler O, Alam M, Amis AA (2008) Changes in knee kinematics reflect the articular geometry after arthroplasty. Clin Orthop Relat Res 466:2491–2499PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Bull AM, Amis AA (1998) Knee joint motion: description and measurement. Proc Inst Mech Eng 212H:357–372CrossRefGoogle Scholar
  6. 6.
    Bottros J, Gad B, Krebs V, Barsoum W (2006) Gap balancing in total knee arthroplasty. J Arthroplasty 21(Supp 1):11–15PubMedCrossRefGoogle Scholar
  7. 7.
    Cross M (1996) Clinical terminology for describing knee instability. Sports Med Arthrosc Rev 4:313–318Google Scholar
  8. 8.
    Dennis DA, Komistek RD, Kim RH, Sharma A (2010) Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res 468:102–107PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    D’lima DD, Patil S, Steklov N, Colwell CW (2007) Dynamic intraoperative ligament balancing for total knee arthroplasty. Clin Orthop Relat Res 463:208–212PubMedGoogle Scholar
  10. 10.
    Elfring R, de la Fuente M, Radermacher K (2010) Assessment of optical localizer accuracy for computer aided surgery systems. Comput Aided Surg 15:1–12PubMedCrossRefGoogle Scholar
  11. 11.
    Farahmand F, Senavongse W, Amis AA (1998) Quantitative study of the quadriceps muscles and trochlear groove geometry related to instability of the patellofemoral joint. J Orthop Res 16:136–143PubMedCrossRefGoogle Scholar
  12. 12.
    Fu Y, Wang M, Lui Y, Fu Q (2012) Alignment outcomes in navigated total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 20:1075–1082PubMedCrossRefGoogle Scholar
  13. 13.
    Ghosh KM, Merican AM, Iranpour F, Deehan DJ, Amis AA (2009) Length change patterns in the extensor retinaculum and the effects of total knee replacement. J Orthop Res 27:865–870PubMedCrossRefGoogle Scholar
  14. 14.
    Ghosh KM, Merican AM, Iranpour F, Deehan DJ, Amis AA (2012) Length change patterns of the collateral ligaments after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 20:1349–1356PubMedCrossRefGoogle Scholar
  15. 15.
    Hetalmish BM, Khan MM, Simunovic N, Al-Harbi HH, Bhandari M, Zalzal PK (2012) Meta-analysis of navigation versus conventional total knee arthroplasty. J Arthroplasty 27:1177–1182CrossRefGoogle Scholar
  16. 16.
    Kamat YD, Aurakzai KM, Adhikari AR (2012) Computer navigation of soft tissue in total knee replacement J Knee Surg 30. doi: 10.1055/s-0032-1322600
  17. 17.
    Kwak DS, Kong CG, Han SH, Kim DH, In Y (2012) Development of a pneumatic tensioning device for gap measurement during total knee arthroplasty. Clin Orthop Surg 4:188–192PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Kwak SD, Ahmad CS, Gardner TR (2000) Hamstrings and iliotibial band forces affect knee kinematics and contact pattern. J Orthop Res 18:101–108PubMedCrossRefGoogle Scholar
  19. 19.
    Lanting BA, Snider MG, Chess DG (2012) Effect of polyethylene component thickness on range of motion and stability in primary total knee arthroplasty. Orthopedics 35:170–174Google Scholar
  20. 20.
    Li G, Rudy TW, Sakane M, Kanamori A, Ma CB, Woo SL (1999) The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL. J Biomech 32:395–400PubMedCrossRefGoogle Scholar
  21. 21.
    Lombard WP, Abbott FM (1907) The mechanical effects produced by the contraction of individual muscles of the thigh of the frog. Am J Physiol 20:1–60Google Scholar
  22. 22.
    Lotke PA, Ecker ML (1977) Influence of positioning of the prosthesis in total knee replacement. J Bone Joint Surg Am 59:77–79PubMedGoogle Scholar
  23. 23.
    Matsumoto T, Muratsu H, Kubo S, Mizuno K, Kinoshita K, Ishida K, Matsushita T, Sasaki K, Tei K, Takayama K, Sasaki H, Oka S, Kurosaka M, Kuroda R (2011) Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 19:880–886PubMedCrossRefGoogle Scholar
  24. 24.
    Matsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R (2011) Soft tissue tension in cruciate-retaining and posterior-stabilized total knee arthroplasty. J Arthroplasty 26:788–795PubMedCrossRefGoogle Scholar
  25. 25.
    Norris M, Gill K, Karadaglis D, Chauhan S (2009) The envelope of laxity and balancing of total knee replacement using navigation. J Bone Joint Surg Br 91B:426Google Scholar
  26. 26.
    Pang HN, Yeo SJ, Chong HC, Chin PL, Ong J, Lo NN (2011) Computer-assisted gap balancing technique improves outcome in total knee arthroplasty, compared with conventional measured resection technique. Knee Surg Sports Traumatol Arthrosc 19:1496–1503PubMedCrossRefGoogle Scholar
  27. 27.
    Pinheiro JC, Bates DM (2000) Mixed-effects models in S and S-PLUS. Springer Verlag, New YorkCrossRefGoogle Scholar
  28. 28.
    Price AJ, Longino D, Rees J, Rout R, Pandit H, Javaid K, Arden N, Cooper C, Carr AJ, Dodd CA, Murray DW, Beard DJ (2010) Are pain and function better measures of outcome than revision rates after TKR in the younger patient? Knee 17:196–199PubMedCrossRefGoogle Scholar
  29. 29.
    Schatzmann L, Brunner P, Staubli HU (1998) Effect of cyclic preconditioning on the tensile properties of human quadriceps tendons and patellar ligaments. Knee Surg Sports Traumatol Asthrosc 6:56–61CrossRefGoogle Scholar
  30. 30.
    Scott CE, Howie CR, Macdonald D, Biant LC (2010) Predicting dissatisfaction following total knee replacement: a prospective study of 1,217 patients. J Bone Joint Surg Br 92:1253–1258PubMedCrossRefGoogle Scholar
  31. 31.
    Stoddard JE, Deehan DJ, Bull AMJ, McCaskie AW, Amis AA (2013) The kinematics and stability of single-radius versus multi-radius femoral components related to mid-range instability after TKA. J Orthop Res 31:53–58PubMedCrossRefGoogle Scholar
  32. 32.
    Song EK, Park SJ, Yoon TR, Park KS, Seo HY, Seon JK (2012) Hi-flexion and gender-specific designs fail to provide significant increases in range of motion during cruciate-retaining total knee arthroplasty. J Arthroplasty 27:1081–1084PubMedCrossRefGoogle Scholar
  33. 33.
    The national joint registry 8th annual report. Sept 2011, pp 95Google Scholar
  34. 34.
    Van Damme G, Defoort K, Ducoulombier Y, Van Glabbeek F, Bellemans J, Victor J (2005) What should the surgeon aim for when performing computer assisted total knee arthroplasty? J Bone Joint Surg Am 87:52–58PubMedCrossRefGoogle Scholar
  35. 35.
    Wada M, Imura S, Baba H, Shimida S (1996) Knee laxity in patients with osteoarthritis and rheumatoid arthritis. Br J Rheumatol 35:560–563PubMedCrossRefGoogle Scholar
  36. 36.
    Winemaker MJ (2002) Perfect balance in total knee arthroplasty: the elusive compromise. J Arthroplasty 17:2–10PubMedCrossRefGoogle Scholar
  37. 37.
    Zalzal P, Papini M, Petruccelli D, de Beer J, Winemaker MJ (2004) An in vivo biomechanical analysis of the soft tissue envelope of osteoarthritic knees. J Arthroplasty 19:217–223PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • K. M. Ghosh
    • 1
  • A. P. Blain
    • 2
  • L. Longstaff
    • 3
  • S. Rushton
    • 2
  • A. A. Amis
    • 4
    • 5
  • D. J. Deehan
    • 1
  1. 1.Newcastle Surgical Training CentreFreeman HospitalNewcastle Upon TyneUK
  2. 2.School of BiologyNewcastle UniversityNewcastle upon TyneUK
  3. 3.Department of Trauma and OrthopaedicsCounty Durham and Darlington NHS Foundation TrustDarlingtonUK
  4. 4.Department of Mechanical EngineeringImperial College LondonLondonUK
  5. 5.Department of Surgery and CancerImperial College LondonLondonUK

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