Abstract
Purpose
Flexion instability following total knee arthroplasty (TKA) is a common indication of early revision. The association between the objective anteroposterior (AP) laxity direction in mid-range flexion and the subjective healing of instability remains unclear; thus, this study aimed to clarify this association.
Methods
In this study, 110 knees (74 females, 92 knees; 16 males, 18 knees) with medial pivot implants were examined with a median age of 79 (range 60–92) years for a median follow-up duration of 22 (range 6–125) months. AP laxity was measured using a KT-1000 arthrometer. Self-reported knee instability score was used for the subjective healing of instability.
Results
Eighty-seven knees did not feel unstable (Group 0), whereas 23 knees felt unstable (Group 1). There was a significant difference in AP displacement [Group 0: median 6 mm; range 2–15 mm and Group 1: median 8 mm; range 4–14; p < 0.0001]. The threshold value of 7 mm was determined using the area under receiver operating characteristic curve of 0.79 [95% confidence interval (CI) 0.69–0.88, p < 0.0001]. In multivariate analysis, AP displacement of ≥7 mm was an independent risk factor for feelings of instability (odds ratio 7.695; 95% CI 2.306–25.674; p = 0.001).
Conclusions
AP laxity of ≥7 mm represents a known cause of feelings of instability. By controlling AP laxity in TKAs, without stiffness in the knee, it is possible to prevent feelings of instability. The clinical relevance is that AP laxity of <7 mm is one of the target areas in TKA.
Level of evidence
IV.
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References
Ariumi A, Sato T, Kobayashi K, Koga Y, Omori G, Minato I, Endo N (2010) Three-dimensional lower extremity alignment in the weight-bearing standing position in healthy elderly subjects. J Orthop Sci 15:64–70
Bellemans J, Robijns F, Duerinckx J, Banks S, Vandenneucker H (2005) The influence of tibial slope of maximal flexion after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 13:193–196
Blaha JD (2004) The rationale for a total knee implant that confers anteroposterior stability throughout range of motion. J Arthroplasty 19:22–26
Blaha JD (2002) A medial pivot geometry. Orthopedics 25:963–964
Colizza WA, Insall JN, Scuderi GR (1995) The posterior-stabilized knee prosthesis: assessment of polyethylene damage and osteolysis after a ten-year minimum follow-up. J Bone Joint Surg Am 77:1713–1720
Dennis D, Komistek R, Mahfouz M (2003) In vivo fluoroscopic analysis of fixed-bearing total knee replacements. Clin Orthop Relat Res 410:114–130
Dejour D, Deschamps G, Garotta L, Dejour H (1999) Laxity in posterior cruciate sparing and posterior stabilized total knee prostheses. Clin Orthop Relat Res 364:182–193
Emmerson KP, Moran CG, Pinder IM (1996) Survivorship analysis of the kinematic stabilizer total knee replacement: a 10–14 year follow-up. J Bone Joint Surg Br 78:441–445
Fehring TK, Valadie AL (1994) Knee instability after total knee arthroplasty. Clin Orthop Relat Res 299:157–162
Felson DT, Niu J, McClennan C, Sack B, Aliabadi P, Hunter DJ, Guermazi A, Englund M (2007) Knee buckling: prevalence, risk factors, and associated limitations in function. Ann Intern Med 147:534–540
Fort-Rodriquez DE, Scuderi GR, Insall JN (1997) Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res 345:79–86
Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD (1998) Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am 80:1132–1145
Ishii Y, Matsuda Y, Ishii R, Sakata S, Omori G (2004) Sagittal laxity in vivo after total knee replacement. Arch Orthop Trauma Surg 125:249–253
Knoop J, van der Leeden M, van der Esch M, Thorstensson CA, Gerritsen M, Voorneman RE, Lems WF, Roorda LD, Dekker J, Steultjens MP (2012) Association of lower muscle strength with self-reported knee instability in osteoarthritis of the knee: results from the Amsterdam Osteoarthritis cohort. Arthritis Care Res (Hoboken) 64:38–45
Kobayashi K, Sakamoto M, Tanabe Y, Ariumi A, Sato T, Omori G, Omori G, Koga Y (2009) Automated image registration for assessing three-dimensional alignment of entire lower extremity and implant position using bi-plane radiography. J Biomech 42:2818–2822
Kuster MS, Bitschanau B, Votruba T (2004) Influence of collateral ligament laxity on patient satisfaction after total knee arthroplasty: a comparative bilateral study. Arch Orthop Trauma Surg 124:415–417
Martin JW, Whiteside LA (1990) The influence of joint line position on knee stability after condylar knee arthroplasty. Clin Orthop Relat Res 259:146–156
Matsuda S, Miura H, Nagamine R, Urabe K, Matsunobu T, Iwamoto Y (1999) Knee stability in posterior cruciate ligament retaining total knee arthroplasty. Clin Orthop Relat Res 366:169–173
Mochizuki T, Sato T, Tanifuji O, Kobayashi K, Koga Y, Yamagiwa H, Omori G, Endo N (2013) In vivo pre- and postoperative three-dimensional knee kinematics in unicompartmental knee arthroplasty. J Orthop Sci 18:54–60
Mochizuki T, Sato T, Blaha JD, Tanifuji O, Kobayashi K, Yamagiwa H, Watanabe S, Matsueda M, Koga Y, Omori G, Endo N (2014) Kinematics of the knee after unicompartmental arthroplasty is not the same as normal and is similar to the kinematics of the knee with osteoarthritis. Knee Surg Sports Traumatol Arthrosc 22:1911–1917
Mochizuki T, Sato T, Blaha JD, Tanifuji O, Kobayashi K, Yamagiwa H, Watanabe S, Koga Y, Omori G, Endo N (2014) The clinical epicondylar axis is not the functional flexion axis of the human knee. J Orthop Sci 19:451–456
Mochizuki T, Sato T, Tanifuji O, Kobayashi K, Yamagiwa H, Watanabe S, Koga Y, Omori G, Endo N (2015) Unicompartmental knee arthroplasty cannot restore the functional flexion axis of a living knee to normal. Knee Surg Sports Traumatol Arthrosc 23:3736–3742
Mochizuki T, Tanifuji O, Koga Y, Sato T, Kobayashi K, Nishino K, Watanabe S, Ariumi A, Fujii T, Yamagiwa H, Omori G, Endo N (2016) Sex differences in femoral deformity determined using three-dimensional assessment for osteoarthritic knees. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4166-2
Mueller JK, Wentorf FA, Moore RE (2014) Femoral and tibial insert downsizing increases the laxity envelope in TKA. Knee Surg Sports Traumatol Arthrosc 22:3003–3011
Murayama T, Sato T, Watanabe S, Kobayashi K, Tanifuji O, Mochizuki T, Yamagiwa H, Koga Y, Omori G, Endo N (2016) Three-dimensional in vivo dynamic motion analysis of anterior cruciate ligament-deficient knees during squatting using geometric center axis of the femur. J Orthop Sci 21:159–165
Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ (1998) Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop Relat Res 356:39–46
Seon JK, Park SJ, Yoon TR, Lee KB, Moon ES, Song EK (2010) The effect of anteroposterior laxity on the range of movement and knee function following a cruciate-retaining total knee replacement. J Bone Joint Surg [Br] 92-B:1090–1095
Sato T, Koga Y, Omori G (2004) Three-dimensional lower extremity alignment assessment system: application to evaluation of component position after total knee arthroplasty. J Arthroplasty 19:620–628
Sato T, Koga Y, Sobue T, Omori G, Tanabe Y, Sakamoto M (2007) Quantitative 3-dimensional analysis of preoperative and postoperative joint lines in total kneearthroplasty: a new concept for evaluation of component alignment. J Arthroplasty 22:560–568
Scuderi GR, Insall JN, Windsor RE, Moran MC (1989) Survivorship of cemented knee replacements. J Bone Joint Surg Br 71:798–803
Tanifuji O, Sato T, Kobayashi K, Mochizuki T, Koga Y, Yamagiwa H, Omori G, Endo N (2011) Three-dimensional in vivo motion analysis of normal knees using single-plane fluoroscopy. J Orthop Sci 16:710–718
Tanifuji O, Sato T, Kobayashi K, Mochizuki T, Koga Y, Yamagiwa H, Omori G, Endo N (2013) Three-dimensional in vivo motion analysis of normal knees employing transepicondylar axis as an evaluation parameter. Knee Surg Sports Traumatol Arthrosc 21:2301–2308
Vince KG (2003) Why knees fail. J Arthroplasty 18:39–44
Vince K (2016) Mid-flexion instability after total knee arthroplasty: woolly thinking or a real concern? Bone Joint J 98-B:84–88
Warren PJ, Olanlokun TK, Walker PS, Walker PS, Iverson BF (1994) Laxity and function in knee replacements. Clin Orthop Relat Res 305:200–208
Watanabe S, Sato T, Omori G, Koga Y, Endo N (2014) Change in tibiofemoral rotational alignment during total knee arthroplasty. J Orthop Sci 19:571–578
Yoon JR, Jeong HI, Oh KJ, Yang JH (2013) In vivo gap analysis in various knee flexion angles during navigation-assisted total knee arthroplasty. J Arthroplasty 28:1796–1800
Zaffagnini S, Bignozzi S, Saffarini M, Colle F, Sharma B, Kinov PS, Marcacci M, Dejour D (2014) Comparison of stability and kinematics of the natural knee versus a PS TKA with a ‘third condyle’. Knee Surg Sports Traumatol Arthrosc 22:1778–1785
Acknowledgements
The authors would like to thank all staff members of the Department of Rehabilitation, Niigata Medical Center, Dr. Kazutaka Otani, Dr. Yuki Takahashi, Dr. Tatsuya Soeno, Dr. Sho Hokari, Dr. Go Omori, Dr. Yoshio Koga.
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Mochizuki, T., Tanifuji, O., Sato, T. et al. Association between anteroposterior laxity in mid-range flexion and subjective healing of instability after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25, 3543–3548 (2017). https://doi.org/10.1007/s00167-016-4375-8
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DOI: https://doi.org/10.1007/s00167-016-4375-8