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Risk factors of de novo hyperextension developed after posterior cruciate ligament substituting total knee arthroplasty: a matched case–control study

Knee Surgery, Sports Traumatology, Arthroscopy volume 31, pages 1123–1131 (2023)Cite this article

Abstract

Purpose

To investigate factors contributing to the de novo hyperextension after posterior cruciate ligament substituting (PS) total knee arthroplasty (TKA).

Methods

Through a retrospective case–control study, de novo hyperextension patients were compared with patients without hyperextension after primary PS TKA. Eighty-five hyperextension patients were compared with 85 patients in a control group matched by age, sex, surgeon and implant. The clinical and radiographic parameters, including the mechanical axis (MA), joint line convergence angle (JLCA), posterior tibial slope angle (PTSA), posterior condylar offset (PCO), and the gamma angle, were evaluated preoperatively and immediate postoperatively. Comparisons between the two groups and logistic regression analysis were performed to investigate factors contributing to de novo hyperextension.

Results

Among the clinical factors, preoperative flexion contracture was less (5° ± 6° vs. 11° ± 6°, p < 0.001) and the range of motion was greater (125° ± 12° vs. 118° ± 5°, p = 0.041) in the de novo hyperextension group than in the control group. Among the radiographic parameters, preoperative and postoperative JLCA were greater (8.1° ± 4.4° vs. 6.1° ± 3.5°, p < 0.001, 1.0° ± 1.3° vs. 0.2° ± 0.8°, p = 0.002, respectively), postoperative PTSA was greater (3.7° ± 2.0° vs. 3.3° ± 1.6°, p < 0.001) and preoperative and postoperative PCO were less in the hyperextension group than in the control group (26.3 mm ± 3.3 mm vs. 29.1 mm ± 3.2 mm, p < 0.001, 26.4 mm ± 3.2 mm vs. 29.1 mm ± 3.0 mm, p < 0.001, respectively), whereas, change in PCO was greater in the hyperextension group (1.1 mm ± 7.7 mm vs. − 0.1 mm ± 3.3 mm, p < 0.001). In multivariate analysis, the degree of medial soft tissue release [odds ratio (OR) 2.83, p = 0.003], flexion contracture [OR 0.86, p = 0.028], postoperative JLCA [OR 2.45, p = 0.004], preoperative PCO and a change in PCO [OR 0.74, p = 0.002, OR 1.89, p = 0.001, respectively] were the factors associated with de novo hyperextension.

Conclusions

An increased degree of medial soft tissue release, small preoperative flexion contracture, increased postoperative JLCA, decreased preoperative PCO and increased change in PCO were risk factors of de novo hyperextension.

Level of evidence

III.

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Abbreviations

PS:

Posterior cruciate ligament substituting

TKA:

Total knee arthroplasty

MA:

Mechanical axis

JLCA:

Joint line convergence angle

PTSA:

Posterior tibial slope angle

PCO:

Posterior condylar offset

PCOR:

Posterior condylar offset ratio

OR:

Odds ratio

aOR:

Adjusted odds ratio

HKA:

Hip–Knee–Ankle

F/U:

Follow-up

ROM:

Range of motion

AP:

Anterior–posterior

PACS:

Picture archiving communication system

ICC:

Intraclass correlation coefficient

CI:

Confidence interval

VIF:

Variation inflation factors

FC:

Flexion contracture

FF:

Further flexion

CT:

Computed tomography

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Acknowledgements

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Funding

No funding was received for this study.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea

    Jong Seop Kim, Chan Hee Cho, Myung Chul Lee & Hyuk-Soo Han

  2. Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea

    Myung Chul Lee & Hyuk-Soo Han

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  1. Jong Seop Kim
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  2. Chan Hee Cho
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  4. Hyuk-Soo Han
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Contributions

JSK and CHC contributed to the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting/revision of article, as well as to the final approval of the article. MCL contributed to the acquisition and interpretation of data, revision of the article, as well as to the final approval of the article. All authors contributed to and approved the final manuscript. HH contributed to the conception and design of the study and drafting/revision of the article.

Corresponding author

Correspondence to Hyuk-Soo Han.

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Conflict of interest

The authors have disclosed that they do not have any conflicts of interest.

Ethical approval

Each author certifies that his institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research. (SNUH IRB No: H-2009-051-1155).

Informed consent

This study is a retrospective study, then we were exempted informed consent by the institutional review board.

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Kim, J.S., Cho, C.H., Lee, M.C. et al. Risk factors of de novo hyperextension developed after posterior cruciate ligament substituting total knee arthroplasty: a matched case–control study. Knee Surg Sports Traumatol Arthrosc 31, 1123–1131 (2023). https://doi.org/10.1007/s00167-021-06618-4

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  • DOI: https://doi.org/10.1007/s00167-021-06618-4

Keywords

  • De novo hyperextension
  • Recurvatum
  • PCL substituting
  • Total knee arthroplasty
  • Total knee replacement