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The posterolateral upslope of a low-conforming insert blocks the medial pivot during a deep knee bend in TKA: a comparative analysis of two implants with different insert conformities

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Tibial insert conformity in total knee arthroplasty (TKA) is of interest due to the potential effect on tibiofemoral kinematics. This study determined differences in anterior–posterior movements of the femoral condyles, pivot locations, and internal tibial rotation in different arcs of flexion for two implants with different insert conformities in kinematically aligned TKA.

Methods

Twenty-five patients treated with a medial and lateral low-conforming, posterior cruciate ligament (PCL) retaining (LC CR) implant followed by a medial ball-in-socket and flat, lateral PCL sacrificing (B-in-S CS) implant in the contralateral knee underwent single-plane fluoroscopy during a deep knee bend. Analysis following 3D-to-2D image registration determined tibiofemoral kinematics and patients completed validated outcome scores for both knees.

Results

The mean follow-up of 1.6 ± 0.4 years for the knee with the B-in-S CS implant was shorter than the 2.7 ± 1.2 years for the LC CR implant. From 0º to 30º of flexion, a medial pivot occurred with the tibia rotating internally approximately 5º with both implants. From 30º to 90º, the pivot remained medial and internal rotation increased to 10º with the B-in-S CS implant. In contrast, neither femoral condyle moved more than 1 mm with the LC CR implant from 30º to 60º, but from 60º to 90º degrees, a lateral pivot occurred and internal rotation increased. Internal rotation of the tibia on the femur from 0° to maximum flexion occurred about a medial pivot similar to the native knee for the B-in-S CS implant and was 4.5° greater than that of the LC CR implant (10.4° vs 5.9°). There was no difference in the median patient-reported outcome scores between implant designs.

Conclusions

Tibial insert conformity is a primary determinant of a medial or lateral pivot during a deep knee bend. One explanation for the transition from a medial to lateral pivot between 30º and 60º with the LC CR implant is the chock-block effect of the insert’s posterolateral upslope which impedes posterior movement of the lateral femoral condyle. Because there is no posterolateral upslope in the insert of the B-in-S CS implant, the tibia pivots medially throughout flexion similar to the native knee.

Level of evidence

Level III.

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Acknowledgements

The authors are grateful to the Orthopaedic Research and Education Foundation (Resident Clinician Scientist Training Grant, 19-504) and Medacta USA, Inc. for financial support.

Funding

Funding provided by the Orthopaedic Research Education and Foundation (Resident Clinician Scientist Training Grant, 19-504) and Medacta USA, Inc.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, UC Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA

    Connor M. Delman

  2. Department of Biomedical Engineering, University of California Davis, One Shields Avenue, Davis, CA, 95616, USA

    Delaney Ridenour

  3. Department of Biomedical Engineering, University of California Davis, Davis, CA, 95616, USA

    Stephen M. Howell

  4. Department of Biomedical Engineering, Department of Mechanical Engineering, Department of Orthopaedic Surgery, UC Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA

    Maury L. Hull

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Contributions

CMD: grant recipient, study design, literature review, fluoroscopic imaging and data acquisition, 3D-to-2D image registration, data analysis and interpretation, statistical analysis, manuscript production, and critical revision of the manuscript. DR: data analysis and interpretation, and statistical analysis. SMH: study design, supervision, data analysis and interpretation, and critical revision of the manuscript. MLH: study design, supervision, data analysis and interpretation, statistical analysis, and critical revision of the manuscript.

Corresponding author

Correspondence to Connor M. Delman.

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Conflict of interest

Dr. Howell—Medacta Inc. Consultant and Royalties. Dr. Hull—Medacta Inc. Research Support, Journal of Biomechanics Editorial Board.

Ethical approval

This was an IRB-approved study at a single institution with the following IRB number 1385598-6 (UC Davis).

Informed consent

Informed consent was obtained for all patients prior to participation in the study.

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Delman, C.M., Ridenour, D., Howell, S.M. et al. The posterolateral upslope of a low-conforming insert blocks the medial pivot during a deep knee bend in TKA: a comparative analysis of two implants with different insert conformities. Knee Surg Sports Traumatol Arthrosc 31, 3627–3636 (2023). https://doi.org/10.1007/s00167-021-06668-8

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  • DOI: https://doi.org/10.1007/s00167-021-06668-8

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