Advertisement

The tibial cut influences the patellofemoral knee kinematics and pressure distribution in total knee arthroplasty with constitutional varus alignment

  • Martin FaschingbauerEmail author
  • S. Hacker
  • A. Seitz
  • L. Dürselen
  • F. Boettner
  • H. Reichel
KNEE
  • 58 Downloads

Abstract

Purpose

The current literature suggests that kinematic total knee arthroplasty (kTKA) may be associated with better outcome scores in patients with constitutional varus alignment. The underlying patellofemoral kinematic changes (patella tilting and patella tracking) and patellofemoral pressure distribution have not yet been described. The present study compared the effects of different tibial cuts, as used in kTKA, on patellofemoral knee kinematics and the pressure distribution, in addition to comparisons with the natural constitutional varus knee.

Methods

Seven cadaveric knee joints with constitutional varus alignment were examined in the native state and after 0°, 3°, or 6° tibial cut cruciate-retaining (CR)-TKA using an established knee joint simulator. The effects on patella rotation/patella tilting, patellofemoral pressure, and patellofemoral length ratios (= patella tracking) were determined. In addition, the natural knee joint and different tibial cuts in CR-TKA were compared (Student’s t test).

Results

In the patellofemoral joint, 6° CR-TKA was associated with the greatest similarity with the natural constitutional varus knee. By contrast, knees subjected to 0° CR-TKA exhibited the largest deviations of patellar kinematics. The smallest difference compared with the natural knee joint concerning patella tilting was found for 6° CR-TKA (mean 0.4°, p < 0.001), and the largest difference was noted for 0° CR-TKA (mean 1.7°, p < 0.001). Concerning patellofemoral pressure, 6° CR-TKA resulted in outcomes most similar to the natural knee joint, featuring a mean difference of 3 MPa. The largest difference from the natural knee joint was identified for 0° CR-TKA, with an average difference of 8.1 MPa (p < 0.001; total mean 17.7 MPa). Meanwhile, 3° and 6° CR-TKA induced medialization of the patella, with the latter inducing the largest medialization value of 4.5 mm at 90° flexion.

Conclusions

The improved outcome parameters in kTKA described in the literature could be attributable to the similar kinematics of the patellofemoral joint relative to the normal state. The current study confirmed the similar kinematics between the native constitutional varus knee joint and knee joints subjected to 3° or 6° CR-TKA (patellofemoral rotation/patella tilting and patella pressure). Conversely, there was pronounced medialization of the patella following 6° CR-TKA. Patella pressure and patella tilting are described in the literature as possible causes of anterior knee pain after TKA, whereas medialization of the patella, which is also influenced by other causes, might play a subordinate role.

Level of evidence

V, Biomechanical study.

Keywords

Knee kinematics TKA Varus alignment Constitutional varus Kinematic TKA Patellofemoral kinematics Patellofemoral pressure 

Notes

Author contributions

FM: planning/conception of the study, collection of data, analysis and interpretation, statistical analysis, and writing and revising article; (orthopedic surgeon). HS: collection of data, analysis and interpretation, and statistical analysis (Dr. bio. hum.). SA and DL: interpretation of data and critical revision of the article (Dr. bio. hum.). BF: critical revision of the article (attending surgeon at HSS). RH: critical revision of the article, final approval of the article, and overall responsibility (surgeon in chief University of Ulm).

Funding

Funding was provided by Deutsche Arthrosehilfe e.V.

Compliance with ethical standards

Conflict of interest

We certify that we have not signed any agreement with commercial interest related to this study, which would, in any way, limit publication of any and all data generated for the study or to delay publication for any reason. Dr. Faschingbauer reports personal fees from Deutsche Arthrosehilfe e.V. during the conduct of the study.

Ethical review committee statement

The authors’ institutional review board approved this study.

References

  1. 1.
    Baker PN, Rushton S, Jameson SS, Reed M, Gregg P, Deehan DJ (2013) Patient satisfaction with total knee replacement cannot be predicted from pre-operative variables alone: a cohort study from the National Joint Registry for England and Wales. Bone Jt J 95-b:1359–1365CrossRefGoogle Scholar
  2. 2.
    Bell SW, Young P, Drury C, Smith J, Anthony I, Jones B et al (2014) Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee 21:272–277CrossRefGoogle Scholar
  3. 3.
    Berend ME, Ritter MA, Meding JB, Faris PM, Keating EM, Redelman R et al (2004) The Chetranjan Ranawat Award: tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res 428:26–34CrossRefGoogle Scholar
  4. 4.
    Dlima DD, Chen PC, Colwell CW (2001) Polyethylene contact stresses, articular congruity, and knee alignment. Clin Orthop Relat Res 392:232–238CrossRefGoogle Scholar
  5. 5.
    Fang DM, Ritter MA, Davis KE (2009) Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty 24:39–43CrossRefGoogle Scholar
  6. 6.
    Fuchs S, Skwara A, Tibesku CO, Rosenbaum D (2005) Retropatellar contact characteristics before and after total knee arthroplasty. Knee 12:9–12CrossRefGoogle Scholar
  7. 7.
    Ghomrawi HM, Mancuso CA, Dunning A, Gonzalez Della Valle A, Alexiades M, Cornell C et al (2017) Do surgeon expectations predict clinically important improvements in WOMAC scores after THA and TKA? Clin Orthop Relat Res.  https://doi.org/10.1007/s11999-017-5331-8 CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclerq V, Hess S (2019) Functional knee phenotypes: a novel classification for phenotyping the coronal lower limb alignment based on the native alignment in young non-osteoarthritic patients. Knee Surg Sports Traumatol Arthrosc.  https://doi.org/10.1007/s00167-019-05509-z CrossRefPubMedGoogle Scholar
  9. 9.
    Hirschmann MT, Testa E, Amsler F, Friederich NF (2013) The unhappy total knee arthroplasty (TKA) patient: higher WOMAC and lower KSS in depressed patients prior and after TKA. Knee Surg Sports Traumatol Arthrosc 21:2405–2411CrossRefGoogle Scholar
  10. 10.
    Hofmann AA, Tkach TK, Evanich CJ, Camargo MP, Zhang Y (1997) Patellar component medialization in total knee arthroplasty. J Arthroplasty 12:155–160CrossRefGoogle Scholar
  11. 11.
    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 471:1000–1007CrossRefGoogle Scholar
  12. 12.
    Hungerford DS (1995) Alignment in total knee replacement. Instr Course Lect 44:455–468PubMedGoogle Scholar
  13. 13.
    Ishikawa M, Kuriyama S, Ito H, Furu M, Nakamura S, Matsuda S (2015) Kinematic alignment produces near-normal knee motion but increases contact stress after total knee arthroplasty: a case study on a single implant design. Knee 22:206–212CrossRefGoogle Scholar
  14. 14.
    Lange T, Schmitt J, Kopkow C, Rataj E, Gunther KP, Lutzner J (2017) What do patients expect from total knee arthroplasty? A Delphi consensus study on patient treatment goals. J Arthroplasty 32:2093–2099.e2091CrossRefGoogle Scholar
  15. 15.
    Leichtle UG, Wunschel M, Leichtle CI, Muller O, Kohler P, Wulker N et al (2014) Increased patellofemoral pressure after TKA: an in vitro study. Knee Surg Sports Traumatol Arthrosc 22:500–508CrossRefGoogle Scholar
  16. 16.
    Lozano R, Campanelli V, Howell S, Hull M (2019) Kinematic alignment more closely restores the groove location and the sulcus angle of the native trochlea than mechanical alignment: implications for prosthetic design. Knee Surg Sports Traumatol Arthrosc 27:1504–1513CrossRefGoogle Scholar
  17. 17.
    Magnussen RA, Weppe F, Demey G, Servien E, Lustig S (2011) Residual varus alignment does not compromise results of TKAs in patients with preoperative varus. Clin Orthop Relat Res 469:3443–3450CrossRefGoogle Scholar
  18. 18.
    Matsuda S, Ishinishi T, White SE, Whiteside LA (1997) Patellofemoral joint after total knee arthroplasty. Effect on contact area and contact stress. J Arthroplasty 12:790–797CrossRefGoogle Scholar
  19. 19.
    Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y (2013) Postoperative alignment and ROM affect patient satisfaction after TKA. Clin Orthop Relat Res 471:127–133CrossRefGoogle Scholar
  20. 20.
    Matsumoto T, Takayama K, Ishida K, Hayashi S, Hashimoto S, Kuroda R (2017) Radiological and clinical comparison of kinematically versus mechanically aligned total knee arthroplasty. Bone Jt J 99-b:640–646CrossRefGoogle Scholar
  21. 21.
    Morgan SS, Bonshahi A, Pradhan N, Gregory A, Gambhir A, Porter ML (2008) The influence of postoperative coronal alignment on revision surgery in total knee arthroplasty. Int Orthop 32:639–642CrossRefGoogle Scholar
  22. 22.
    Murakami AM, Hash TW, Hepinstall MS, Lyman S, Nestor BJ, Potter HG (2012) MRI evaluation of rotational alignment and synovitis in patients with pain after total knee replacement. J Bone Jt Surg Br 94:1209–1215CrossRefGoogle Scholar
  23. 23.
    Odum SM, Fehring TK (2016) Can original knee society scores be used to estimate new 2011 knee society scores? Clin Orthop Relat Res 475(1):160–167CrossRefGoogle Scholar
  24. 24.
    Parratte S, Pagnano MW, Trousdale RT, Berry DJ (2010) Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Jt Surg Am 92:2143–2149CrossRefGoogle Scholar
  25. 25.
    Petersen W, Rembitzki IV, Bruggemann GP, Ellermann A, Best R, Koppenburg AG et al (2014) Anterior knee pain after total knee arthroplasty: a narrative review. Int Orthop 38:319–328CrossRefGoogle Scholar
  26. 26.
    Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA (2011) The effect of alignment and BMI on failure of total knee replacement. J Bone Jt Surg Am 93:1588–1596CrossRefGoogle Scholar
  27. 27.
    Ritter MA, Faris PM, Keating M, Meding JB (1994) Postoperative alignment of total knee replacement. Clin Orthop Relat Res 299:153–156Google Scholar
  28. 28.
    Riviere C, Iranpour F, Auvinet E, Howell S, Vendittoli PA, Cobb J et al (2017) Alignment options for total knee arthroplasty: a systematic review. Orthop Traumatol Surg Res 103:1047–1056CrossRefGoogle Scholar
  29. 29.
    Slevin O, Hirschmann A, Schiapparelli FF, Amsler F, Huegli RW, Hirschmann MT (2018) Neutral alignment leads to higher knee society scores after total knee arthroplasty in preoperatively non-varus patients: a prospective clinical study using 3D-CT. Knee Surg Sports Traumatol Arthrosc 26:1602–1609CrossRefGoogle Scholar
  30. 30.
    Steinbruck A, Fottner A, Schroder C, Woiczinski M, Schmitt-Sody M, Muller T et al (2017) Influence of mediolateral tibial baseplate position in TKA on knee kinematics and retropatellar pressure. Knee Surg Sports Traumatol Arthrosc 25:2602–2608CrossRefGoogle Scholar
  31. 31.
    Steinbrück A, Schröder C, Woiczinski M, Fottner A, Müller PE, Jansson V (2013) Patellofemoral contact patterns before and after total knee arthroplasty: an in vitro measurement. Biomed Eng Online 12:58CrossRefGoogle Scholar
  32. 32.
    Steinbruck A, Schroder C, Woiczinski M, Schmidutz F, Muller PE, Jansson V et al (2017) Mediolateral femoral component position in TKA significantly alters patella shift and femoral roll-back. Knee Surg Sports Traumatol Arthrosc 25:3561–3568CrossRefGoogle Scholar
  33. 33.
    Tanikawa H, Tada M, Harato K, Okuma K, Nagura T (2017) Influence of total knee arthroplasty on patellar kinematics and patellofemoral pressure. J Arthroplasty 32:280–285CrossRefGoogle Scholar
  34. 34.
    Theodore W, Twiggs J, Kolos E, Roe J, Fritsch B, Dickison D et al (2017) Variability in static alignment and kinematics for kinematically aligned TKA. Knee 24:733–744CrossRefGoogle Scholar
  35. 35.
    Vanlommel L, Vanlommel J, Claes S, Bellemans J (2013) Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 21:2325–2330CrossRefGoogle Scholar
  36. 36.
    Victor J, Labey L, Wong P, Innocenti B, Bellemans J (2010) The influence of muscle load on tibiofemoral knee kinematics. J Orthop Res 28:419–428PubMedGoogle Scholar
  37. 37.
    Victor J, Van Glabbeek F, Vander Sloten J, Parizel PM, Somville J, Bellemans J (2009) An experimental model for kinematic analysis of the knee. J Bone Jt Surg Am 91(Suppl 6):150–163CrossRefGoogle Scholar
  38. 38.
    Wilharm A, Hurschler C, Dermitas T, Bohnsack M (2013) Use of Tekscan K-scan sensors for retropatellar pressure measurement avoiding errors during implantation and the effects of shear forces on the measurement precision. Biomed Res Int 2013:829171CrossRefGoogle Scholar
  39. 39.
    Woiczinski M, Kistler M, Schroder C, Braun C, Weber P, Muller PE et al (2019) TKA design-integrated trochlea groove rotation reduces patellofemoral pressure. Knee Surg Sports Traumatol Arthrosc 27:1680–1692CrossRefGoogle Scholar
  40. 40.
    Worlicek M, Moser B, Maderbacher G, Zentner R, Zeman F, Grifka J et al (2017) The influence of varus and valgus deviation on patellar kinematics in healthy knees: an exploratory cadaver study. Knee 24:711–717CrossRefGoogle Scholar
  41. 41.
    Young SW, Walker ML, Bayan A, Briant-Evans T, Pavlou P, Farrington B (2017) The Chitranjan S. Ranawat Award: no difference in 2-year functional outcomes using kinematic versus mechanical alignment in TKA: a randomized controlled clinical trial. Clin Orthop Relat Res 475:9–20CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryRKU, University of UlmUlmGermany
  2. 2.Institute of Orthopaedic Research and BiomechanicsUniversity of UlmUlmGermany
  3. 3.Hospital for Special SurgeryNew YorkUSA

Personalised recommendations