Skip to main content
SpringerLink
Log in

Kinematically aligned total knee arthroplasty reproduces native patellofemoral biomechanics during deep knee flexion

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The implant positioning for kinematically aligned total knee arthroplasty (TKA) differs fundamentally from conventional mechanically aligned TKA. This difference may affect patellofemoral (PF) biomechanics after TKA. This cadaveric study tested the hypothesis that kinematically aligned TKA would restore PF biomechanics to the native condition better than mechanically aligned TKA.

Methods

Seven pairs (14 knees) of fresh-frozen cadavers were tested. All specimens were mounted on a customized knee-testing system and digitized using a Microscribe 3DLX instrument (Revware Inc., Raleigh, NC, USA) to measure patellar kinematics in terms of patellar varus/valgus rotation, medial/lateral position, flexion/extension rotation and proximal/distal position at knee flexion angles of 0°, 30°, 60°, 90°, and 120°. The medial and lateral PF joint contact pressure distributions at 120° of knee flexion were measured using a K-scan system (Tekscan Inc., Boston, MA, USA). All patellae remained unresurfaced. For each pair, one knee was randomly assigned to kinematically aligned TKA and the other to mechanically aligned TKA performed using the conventional measured resection technique. During kinematically aligned TKA, the amount of femur and tibia resected was equivalent to implant thickness to maintain the patient-specific joint line. All patellar kinematics were measured and compared between the native condition and after surgery.

Results

The patellae of mechanically aligned TKA rotated more valgus and was positioned more laterally compared with those of kinematically aligned TKA at knee flexion angles ≥ 90°. Neither the patellar flexion/extension rotation nor the proximal/distal position differed between either prosthetic knee design and the native knee at all flexion angles. The contact pressure distribution between the medial and lateral PF joint after kinematically aligned TKA were similar to those of the native knee, while the lateral PF joint contact pressure after mechanically aligned TKA was higher than that of the native knee (p = 0.038).

Conclusions

Kinematically aligned TKA better restores patellar kinematics and PF contact pressure distribution to the native condition than mechanically aligned TKA during deep knee flexion. These findings provide clues to understand why kinematically aligned TKA is associated with less anterior knee pain and better PF functional performance compared to mechanically aligned TKA. Patients undergoing kinematically aligned TKA may experience a more normal feeling during deep knee flexion activities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Abdel MP, Oussedik S, Parratte S, Lustig S, Haddad FS (2014) Coronal alignment in total knee replacement: historical review, contemporary analysis, and future direction. Bone Jt J 96-b(7):857–862

    Article  CAS  Google Scholar 

  2. Bellemans J, Colyn W, Vandenneucker H, Victor J (2012) The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 470(1):45–53

    Article  PubMed  Google Scholar 

  3. Brar AS, Howell SM, Hull ML, Mahfouz MR (2016) Does kinematic alignment and flexion of a femoral component designed for mechanical alignment reduce the proximal and lateral reach of the trochlea? J Arthroplasty 31(8):1808–1813

    Article  PubMed  Google Scholar 

  4. Breugem SJ, van Ooij B, Haverkamp D, Sierevelt IN, van Dijk CN (2014) No difference in anterior knee pain between a fixed and a mobile posterior stabilized total knee arthroplasty after 7.9 years. Knee Surg Sports Traumatol Arthrosc 22(3):509–516

    Article  PubMed  Google Scholar 

  5. Bryant BJ, Tilan JU, McGarry MH, Takenaka N, Kim WC, Lee TQ (2014) The biomechanical effect of increased valgus on total knee arthroplasty: a cadaveric study. J Arthroplasty 29(4):722–726

    Article  PubMed  Google Scholar 

  6. Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M (2017) PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 25(6):1743–1748

    Article  PubMed  Google Scholar 

  7. Courtney PM, Lee GC (2017) Early outcomes of kinematic alignment in primary total knee arthroplasty: a meta-analysis of the literature. J Arthroplasty 32(6):2028–2032

    Article  PubMed  Google Scholar 

  8. Delport H, Labey L, Innocenti B, De Corte R, Vander Sloten J, Bellemans J (2015) Restoration of constitutional alignment in TKA leads to more physiological strains in the collateral ligaments. Knee Surg Sports Traumatol Arthrosc 23(8):2159–2169

    Article  PubMed  Google Scholar 

  9. Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG (2014) A randomised controlled trial of kinematically and mechanically aligned total knee replacements: two-year clinical results. Bone Jt J 96-b(7):907–913

    Article  CAS  Google Scholar 

  10. Fornalski S, McGarry MH, Bui CN, Kim WC, Lee TQ (2012) Biomechanical effects of joint line elevation in total knee arthroplasty. Clin Biomech (Bristol Avon) 27(8):824–829

    Article  Google Scholar 

  11. Glogaza A, Schroder C, Woiczinski M, Muller P, Jansson V, Steinbruck A (2018) Medial stabilized and posterior stabilized TKA affect patellofemoral kinematics and retropatellar pressure distribution differently. Knee Surg Sports Traumatol Arthrosc 26(6):1743–1750

    Article  PubMed  Google Scholar 

  12. Hofer JK, Gejo R, McGarry MH, Lee TQ (2012) Effects of kneeling on tibiofemoral contact pressure and area in posterior cruciate-retaining and posterior cruciate-sacrificing total knee arthroplasty. J Arthroplasty 27(4):620–624

    Article  PubMed  Google Scholar 

  13. 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(3):1000–1007

    Article  PubMed  Google Scholar 

  14. Howell SM, Papadopoulos S, Kuznik K, Ghaly LR, Hull ML (2015) Does varus alignment adversely affect implant survival and function six years after kinematically aligned total knee arthroplasty? Int Orthop 39(11):2117–2124

    Article  PubMed  Google Scholar 

  15. Howell SM, Papadopoulos S, Kuznik KT, Hull ML (2013) Accurate alignment and high function after kinematically aligned TKA performed with generic instruments. Knee Surg Sports Traumatol Arthrosc 21(10):2271–2280

    Article  PubMed  Google Scholar 

  16. Hutt J, Masse V, Lavigne M, Vendittoli PA (2016) Functional joint line obliquity after kinematic total knee arthroplasty. Int Orthop 40(1):29–34

    Article  PubMed  Google Scholar 

  17. 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(3):206–212

    Article  PubMed  Google Scholar 

  18. Ji HM, Han J, Jin DS, Seo H, Won YY (2016) Kinematically aligned TKA can align knee joint line to horizontal. Knee Surg Sports Traumatol Arthrosc 24(8):2436–2441

    Article  PubMed  Google Scholar 

  19. Koh IJ, Kwak DS, Kim TK, Park IJ, In Y (2014) How effective is multiple needle puncturing for medial soft tissue balancing during total knee arthroplasty? A cadaveric study. J Arthroplasty 29(12):2478–2483

    Article  PubMed  Google Scholar 

  20. 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(3):500–508

    Article  PubMed  Google Scholar 

  21. Nakamura S, Tian Y, Tanaka Y, Kuriyama S, Ito H, Furu M et al (2017) The effects of kinematically aligned total knee arthroplasty on stress at the medial tibia: a case study for varus knee. Bone Jt Res 6(1):43–51

    Article  CAS  Google Scholar 

  22. Nedopil AJ, Howell SM, Hull ML (2017) What clinical characteristics and radiographic parameters are associated with patellofemoral instability after kinematically aligned total knee arthroplasty? Int Orthop 41(2):283–291

    Article  PubMed  Google Scholar 

  23. Nedopil AJ, Singh AK, Howell SM, Hull ML (2018) Does calipered kinematically aligned TKA restore native left to right symmetry of the lower limb and improve function? J Arthroplasty 33(2):398–406

    Article  PubMed  Google Scholar 

  24. Riley J, Roth JD, Howell SM, Hull ML (2018) Internal-external malalignment of the femoral component in kinematically aligned total knee arthroplasty increases tibial force imbalance but does not change laxities of the tibiofemoral joint. Knee Surg Sports Traumatol Arthrosc 26(6):1618–1628

    Article  PubMed  Google Scholar 

  25. Riviere C, Iranpour F, Harris S, Auvinet E, Aframian A, Parratte S et al (2018) Differences in trochlear parameters between native and prosthetic kinematically or mechanically aligned knees. Orthop Traumatol Surg Res 104(2):165–170

    Article  CAS  PubMed  Google Scholar 

  26. Roth JD, Howell SM, Hull ML (2018) Kinematically aligned total knee arthroplasty limits high tibial forces, differences in tibial forces between compartments, and abnormal tibial contact kinematics during passive flexion. Knee Surg Sports Traumatol Arthrosc 26(6):1589–1601

    Article  PubMed  Google Scholar 

  27. Sharma A, Grieco TF, Zingde SM, Dennis DA, Anderle MR, Komistek RD (2017) In vivo three-dimensional patellar mechanics: normal knees compared with domed and anatomic patellar components. J Bone Jt Surg Am 99(5):e18

    Article  Google Scholar 

  28. Slevin O, Schmid FA, Schiapparelli F, Rasch H, Hirschmann MT (2018) Increased in vivo patellofemoral loading after total knee arthroplasty in resurfaced patellae. Knee Surg Sports Traumatol Arthrosc 26(6):1805–1810

    Article  PubMed  Google Scholar 

  29. Slevin O, Schmid FA, Schiapparelli FF, Rasch H, Amsler F, Hirschmann MT (2017) Coronal femoral TKA position significantly influences in vivo patellar loading in unresurfaced patellae after primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25(11):3605–3610

    Article  PubMed  Google Scholar 

  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(8):2602–2608

    Article  PubMed  Google Scholar 

  31. Steinbruck A, Schroder C, Woiczinski M, Fottner A, Muller PE, Jansson V (2013) Patellofemoral contact patterns before and after total knee arthroplasty: an in vitro measurement. Biomed Eng Online 12:58

    Article  PubMed  PubMed Central  Google Scholar 

  32. Steinbruck A, Schroder C, Woiczinski M, Muller T, Muller PE, Jansson V et al (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  PubMed  Google Scholar 

  33. 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(11):3561–3568

    Article  PubMed  Google Scholar 

  34. Stoddard JE, Deehan DJ, Bull AM, McCaskie AW, Amis AA (2014) No difference in patellar tracking between symmetrical and asymmetrical femoral component designs in TKA. Knee Surg Sports Traumatol Arthrosc 22(3):534–542

    Article  CAS  PubMed  Google Scholar 

  35. 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(1):280–285

    Article  PubMed  Google Scholar 

  36. 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(4):733–744

    Article  PubMed  Google Scholar 

  37. Vandekerckhove PTK, Matlovich N, Teeter MG, MacDonald SJ, Howard JL, Lanting BA (2017) The relationship between constitutional alignment and varus osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 25(9):2873–2879

    Article  PubMed  Google Scholar 

  38. Werth L, Saffarini M, Amsler F, Abdelkafy A, Hirschmann MT (2017) The need for secondary resurfacing is affected by trochlear height in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25(12):3818–3823

    Article  PubMed  Google Scholar 

  39. Wickiewicz TL, Roy RR, Powell PL, Edgerton VR (1983) Muscle architecture of the human lower limb. Clin Orthop Relat Res (179):275–283

Download references

Acknowledgements

All implants and surgical instruments were donated by Corentec Co. Ltd (Seoul, Republic of Korea). We thank Ji Hyun Ahn MD, PhD of Dongguk University Ilsan Hospital, and Adam Kantor BA, of the Orthopedic Biomechanical Laboratory, for assistance in testing. We also thank the donors and their families.

Funding

Partial funding provided by Veterans Affairs Rehabilitation Research and Development Merit Review and the John C. Griswold Foundation.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, St. Paul’s Hospital, Wangsan-ro 180, Dongdaemun-gu, Seoul, 02559, Republic of Korea

    In Jun Koh

  2. Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, Bucheon, 14647, Republic of Korea

    Il Jung Park

  3. Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea

    In Jun Koh & Il Jung Park

  4. Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA

    Charles C. Lin, Nilay A. Patel, Christen E. Chalmers, Michelle H. McGarry & Thay Q. Lee

  5. Department of Orthopaedic Surgery, University of California, Irvine, CA, USA

    Nilay A. Patel & Thay Q. Lee

  6. Department of Orthopaedics and Traumatology, Inselspital Bern, University Hospital, Bern, Switzerland

    Mauro Maniglio

Authors
  1. In Jun Koh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Il Jung Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Charles C. Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nilay A. Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christen E. Chalmers
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mauro Maniglio
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Michelle H. McGarry
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Thay Q. Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to In Jun Koh.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding authors identify the following possible conflict of interest: Corentec Co. Ltd. donated all prostheses used in this study. The company had no input into the study design, or data collection or interpretation. The company was not involved in manuscript preparation or the decision to submit the article to this journal.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

For this type of study formal consent is not required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Koh, I.J., Park, I.J., Lin, C.C. et al. Kinematically aligned total knee arthroplasty reproduces native patellofemoral biomechanics during deep knee flexion. Knee Surg Sports Traumatol Arthrosc 27, 1520–1528 (2019). https://doi.org/10.1007/s00167-018-5270-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-018-5270-2

Keywords

Search

Navigation