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.
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.
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).
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, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Hutt J, Masse V, Lavigne M, Vendittoli PA (2016) Functional joint line obliquity after kinematic total knee arthroplasty. Int Orthop 40(1):29–34
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Wickiewicz TL, Roy RR, Powell PL, Edgerton VR (1983) Muscle architecture of the human lower limb. Clin Orthop Relat Res (179):275–283
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.
Partial funding provided by Veterans Affairs Rehabilitation Research and Development Merit Review and the John C. Griswold Foundation.
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.
This article does not contain any studies with human participants performed by any of the authors.
For this type of study formal consent is not required.
About this article
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
- Patellofemoral kinematics
- Total knee arthroplasty
- Kinematic alignment
- Mechanical alignment