Do modern total knee replacements improve tibial coverage?

Knee Surgery, Sports Traumatology, Arthroscopy volume 26, pages3219–3229(2018)Cite this article

Abstract

Purpose

The purpose of the present study is to compare newer designs of various symmetric and asymmetric tibial components and measure tibial bone coverage using the rotational safe zone defined by two commonly utilized anatomic rotational landmarks.

Methods

Computed tomography scans (CT scans) of one hundred consecutive patients scheduled for total knee arthroplasty were obtained pre-operatively. A virtual proximal tibial cut was performed and two commonly used rotational axes were added for each image: the medio-lateral axis (ML-axis) and the medial 1/3 tibial tubercle axis (med-1/3-axis). Different symmetric and asymmetric implant designs were then superimposed in various rotational positions for best cancellous and cortical coverage. The images were imported to a public domain imaging software, and cancellous and cortical bone coverage was computed for each image, with each implant design in various rotational positions.

Results

One single implant type could not be identified that provided the best cortical and cancellous coverage of the tibia, irrespective of using the med-1/3-axis or the ML-axis for rotational alignment. However, it could be confirmed that the best bone coverage was dependent on the selected rotational landmark. Furthermore, improved bone coverage was observed when tibial implant positions were optimized between the two rotational axes.

Conclusions

Tibial coverage is similar for symmetric and asymmetric designs, but depends on the rotational landmark for which the implant is designed. The surgeon has the option to improve tibial coverage by optimizing placement between the two anatomic rotational alignment landmarks, the medial 1/3 and the ML-axis. Surgeons should be careful assessing intraoperative rotational tibial placement using the described anatomic rotational landmarks to optimize tibial bony coverage without compromising patella tracking.

Level of Evidence

III.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

US$ 39.95

Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Abbreviations

TKR:

Total knee replacement

med-1/3-axis:

Medial-third-axis

ML-axis:

Medial-lateral-axis

TPC:

Tibial plateau center

MPC:

Medial plateau center

LPC:

Lateral plateau center

RGB:

Red Green Blue

PCL:

Posterior cruciate ligament

PTA:

Posterior tibial axis

AP:

Anteroposterior

ML:

Mediolateral

MCL:

Medio-collateral ligament

Sym1:

Attune

Sym2:

Sigma

Asym1:

Journey

Asym2:

Persona

References

  1. 1.

    Akagi M, Matsusue Y, Mata T, Asada Y, Horiguchi M, Iida H, Nakamura T (1999) Effect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop Relat Res 366:155–163

    Article  Google Scholar 

  2. 2.

    Akagi M, Oh M, Nonaka T, Tsujimoto H, Asano T, Hamanishi C (2004) An anteroposterior axis of the tibia for total knee arthroplasty. Clin Orthop Relat Res 420:213–219

    Article  Google Scholar 

  3. 3.

    Berger RA, Crossett LS, Jacobs JJ, Rubash HE (1998) Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 356:144–153

    Article  Google Scholar 

  4. 4.

    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  Google Scholar 

  5. 5.

    Cicchetti DV (1994) Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess 6(4):284–290

    Article  Google Scholar 

  6. 6.

    Clary C, Aram L, Deffenbaugh D, Heldreth M (2014) Tibial base design and patient morphology affecting tibial coverage and rotational alignment after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22(12):3012–3018

    Article  Google Scholar 

  7. 7.

    Cobb JP, Dixon H, Dandachli W, Iranpour F (2008) The anatomical tibial axis: reliable rotational orientation in knee replacement. J Bone Joint Surg Br 90(8):1032–1038

    CAS  Article  Google Scholar 

  8. 8.

    Dai Y, Scuderi GR, Bischoff JE, Bertin K, Tarabichi S, Rajgopal A (2014) Anatomic tibial component design can increase tibial coverage and rotational alignment accuracy: a comparison of six contemporary designs. Knee Surg Sports Traumatol Arthrosc 22(12):2911–2923

    Article  Google Scholar 

  9. 9.

    Dao Trong ML, Diezi C, Goerres G, Helmy N (2015) Improved positioning of the tibial component in unicompartmental knee arthroplasty with patient-specific cutting blocks. Knee Surg Sports Traumatol Arthrosc 23(7):1993–1998

    CAS  Article  Google Scholar 

  10. 10.

    De Valk EJ, Noorduyn JCA, Mutsaerts ELAR. (2016) How to assess femoral and tibial component rotation after total knee arthroplasty with computed tomography: a systematic review. Knee Surg Sports Traumatol Arthrosc 24(11):3517–3528

    Article  Google Scholar 

  11. 11.

    Fitz W, Bliss R, Losina E (2013) Current fit of medial and lateral unicompartmental knee arthroplasty. Acta Orthop Belg 79(2):191–196

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Gudena R, Pilambaraei MA, Werle J, Shrive NG, Frank CB (2013) A safe overhang limit for unicompartmental knee arthroplasties based on medial collateral ligament strains: an in vitro study. J Arthroplasty 28(2):227–233

    Article  Google Scholar 

  13. 13.

    Hirakawa M, Miyazaki M, Ikeda S, Matsumoto Y, Kondo M, Tsumura H (2017) Evaluation of the rotational alignment of the tibial component in total knee arthroplasty: position prioritizing maximum coverage. Eur J Orthop Surg Traumatol 27(1):119–124

    Article  Google Scholar 

  14. 14.

    Hirschmann MT, Konala P, Amsler F, Iranpour F, Friederich NF, Cobb JP (2011) The position and orientation of total knee replacement components: a comparison of conventional radiographs, transverse 2D-CT slices and 3D-CT reconstruction. J Bone Joint Surg Br 93(5):629–633

    CAS  Article  Google Scholar 

  15. 15.

    Incavo SJ, Coughlin K, Pappas C, Beynnon B (2003) Anatomic rotational relationships of the proximal tibia, distal femur, and patella: implications for rotational alignment in total knee arthroplasty. J Arthroplasty 18(5):643–648

    Article  Google Scholar 

  16. 16.

    Keshmiri A, Maderbacher G, Baier C, Zeman F, Grifka J, Springorum HR (2016) Significant influence of rotational limb alignment parameters on patellar kinematics: an in vitro study. Knee Surg Sports Traumatol Arthrosc 24(8):2407–2414

    Article  Google Scholar 

  17. 17.

    Kutzner I (2012) Influence of limb alignment on mediolateral loading in total knee replacement: in vivo measurements in five patients. J Bone Joint Surg Am 94(11):1023

    Article  Google Scholar 

  18. 18.

    Lawrie CM, Noble PC, Ismaily SK, Stal D, Incavo SJ (2011) The flexion-extension axis of the knee and its relationship to the rotational orientation of the tibial plateau. J Arthroplasty 26(6):53–58.e1

    Article  Google Scholar 

  19. 19.

    Lützner J, Krummenauer F, Günther K, Kirschner S (2010) Rotational alignment of the tibial component in total knee arthroplasty is better at the medial third of tibial tuberosity than at the medial border. BMC Musculoskelet Disord 11:57

    Article  Google Scholar 

  20. 20.

    Martin S, Saurez A, Ismaily S, Ashfaq K, Noble P, Incavo SJ (2014) Maximizing tibial coverage is detrimental to proper rotational alignment. Clin Orthop Relat Res 472(1):121–125

    Article  Google Scholar 

  21. 21.

    Nicoll D, Rowley DI (2010) Internal rotational error of the tibial component is a major cause of pain after total knee replacement. J Bone Joint Surg Br 92(9):1238–1244

    CAS  Article  Google Scholar 

  22. 22.

    Servien E, Saffarini M, Lustig S, Chomel S, Neyret P (2008) Lateral versus medial tibial plateau: morphometric analysis and adaptability with current tibial component design. Knee Surg Sports Traumatol Arthrosc 16(12):1141–1145

    CAS  Article  Google Scholar 

  23. 23.

    Shrout P, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86(2):420–428

    CAS  Article  Google Scholar 

  24. 24.

    Silva A, Pinto E, Sampaio R (2016) Rotational alignment in patient-specific instrumentation in TKA: MRI or CT? Knee Surg Sports Traumatol Arthrosc 24(11):3648–3652

    Article  Google Scholar 

  25. 25.

    Steinbrück A, Schröder C, Woiczinski M, Müller T, Müller PE, Jansson V, Fottner A (2016) Influence of tibial rotation in total knee arthroplasty on knee kinematics and retropatellar pressure: an in vitro study. Knee Surg Sports Traumatol Arthrosc 24(8):2395–2401

    Article  Google Scholar 

  26. 26.

    Stulberg SD, Goyal N (2015) Which tibial tray design achieves maximum coverage and ideal rotation: anatomic, symmetric, or asymmetric? An MRI-based study. J Arthroplasty 30(10):1839–1841

    Article  Google Scholar 

  27. 27.

    Uehara K, Kadoya Y, Kobayashi A, Ohashi H, Yamano Y (2002) Bone anatomy and rotational alignment in total knee arthroplasty. Clin Orthop Relat Res 402:196–201

    Article  Google Scholar 

  28. 28.

    Wernecke G, Harris I, Houang M, Seeto B, Chen D, MacDessi S (2012) Comparison of tibial bone coverage of 6 knee prostheses: a magnetic resonance imaging study with controlled rotation. J Orthop Surg (Hong Kong) 20(2):143–147

    Article  Google Scholar 

  29. 29.

    Westrich G, Haas S, Insall J, Frachie A (1995) Resection spe 373 cimen analysis of proximal tibial anatomy based on 100 total knee arthroplasty specimens. J Arthroplasty 10(1):47–51

    CAS  Article  Google Scholar 

Download references

Author information

Affiliations

  1. University of Ulm, Helmholzstraße 16, 89081, Ulm, Germany

    Malin Meier

  2. Mayo Clinic Health System in Eau Claire, Luther Campus Clinic, 1400 Bellinger Street, Eau Claire, WI, 54703, USA

    Jonathan Webb

  3. Orthopedic Surgery, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, 02115, USA

    Jamie E. Collins & Wolfgang Fitz

  4. Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Germany

    Johannes Beckmann

Authors
  1. Malin Meier
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jonathan Webb
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jamie E. Collins
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Johannes Beckmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wolfgang Fitz
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MM: acquisition of data, analysis and interpretation of data, drafting of the manuscript, preparing of graphs and tables, has given final approval of the version to be published, participated in the design of the study, agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JW: revising the manuscript critically for important intellectual content, participated in the design of the study. JC: participated in the design of the study and performed the statistical analysis. JB: revising the manuscript critically for important intellectual content, discussion of background and results, analysis and interpretation of data, have given final approval of the version to be published, agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. WF: provided conception and design of the study, general supervision of the research group, analysis and interpretation of data, discussion of background and results, revising the manuscript critically for important intellectual content, final approval of the version to be published, agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Wolfgang Fitz.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Funding

There was no outside funding or grants received that assisted in this study.

Ethical approval

This study has been performed in accordance with ethical standards concerning investigations in the United States of America.

Informed consent

For this type of article informed consent is not required.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Meier, M., Webb, J., Collins, J.E. et al. Do modern total knee replacements improve tibial coverage?. Knee Surg Sports Traumatol Arthrosc 26, 3219–3229 (2018). https://doi.org/10.1007/s00167-018-4836-3

Download citation

Keywords

  • Total knee arthroplasty
  • Tibial coverage
  • Rotational alignment
  • Total knee replacement
  • Tibial rotation