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Association between anteroposterior laxity in mid-range flexion and subjective healing of instability after total knee arthroplasty

  • Knee
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

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

  1. 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

    Article  PubMed  Google Scholar 

  2. 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

    Article  CAS  PubMed  Google Scholar 

  3. Blaha JD (2004) The rationale for a total knee implant that confers anteroposterior stability throughout range of motion. J Arthroplasty 19:22–26

    Article  PubMed  Google Scholar 

  4. Blaha JD (2002) A medial pivot geometry. Orthopedics 25:963–964

    PubMed  Google Scholar 

  5. 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

    Article  CAS  PubMed  Google Scholar 

  6. Dennis D, Komistek R, Mahfouz M (2003) In vivo fluoroscopic analysis of fixed-bearing total knee replacements. Clin Orthop Relat Res 410:114–130

    Article  Google Scholar 

  7. 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

    Article  Google Scholar 

  8. 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

    CAS  PubMed  Google Scholar 

  9. Fehring TK, Valadie AL (1994) Knee instability after total knee arthroplasty. Clin Orthop Relat Res 299:157–162

    Google Scholar 

  10. 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

    Article  PubMed  Google Scholar 

  11. Fort-Rodriquez DE, Scuderi GR, Insall JN (1997) Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res 345:79–86

    Google Scholar 

  12. 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

    Article  CAS  PubMed  Google Scholar 

  13. 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

    Article  PubMed  Google Scholar 

  14. 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

    Article  Google Scholar 

  15. 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

    Article  PubMed  Google Scholar 

  16. 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

    Article  CAS  PubMed  Google Scholar 

  17. 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

    Google Scholar 

  18. 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

    Article  Google Scholar 

  19. 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

    Article  PubMed  Google Scholar 

  20. 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

    Article  PubMed  Google Scholar 

  21. 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

    Article  PubMed  Google Scholar 

  22. 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

    Article  PubMed  Google Scholar 

  23. 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

    Google Scholar 

  24. 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

    Article  PubMed  PubMed Central  Google Scholar 

  25. 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

    Article  PubMed  Google Scholar 

  26. 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

    Article  Google Scholar 

  27. 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

    Article  Google Scholar 

  28. 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

    Article  PubMed  Google Scholar 

  29. 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

    Article  PubMed  Google Scholar 

  30. Scuderi GR, Insall JN, Windsor RE, Moran MC (1989) Survivorship of cemented knee replacements. J Bone Joint Surg Br 71:798–803

    Article  CAS  PubMed  Google Scholar 

  31. 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

    Article  PubMed  Google Scholar 

  32. 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

    Article  PubMed  Google Scholar 

  33. Vince KG (2003) Why knees fail. J Arthroplasty 18:39–44

    Article  PubMed  Google Scholar 

  34. Vince K (2016) Mid-flexion instability after total knee arthroplasty: woolly thinking or a real concern? Bone Joint J 98-B:84–88

    Article  CAS  PubMed  Google Scholar 

  35. Warren PJ, Olanlokun TK, Walker PS, Walker PS, Iverson BF (1994) Laxity and function in knee replacements. Clin Orthop Relat Res 305:200–208

    Article  Google Scholar 

  36. 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

    Article  PubMed  Google Scholar 

  37. 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

    Article  PubMed  Google Scholar 

  38. 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

    Article  PubMed  Google Scholar 

Download references

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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Correspondence to Tomoharu Mochizuki.

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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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