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Medial stability and lateral flexibility of the collateral ligaments during mid-range flexion in medial-pivot total knee arthroplasty patients demonstrates favorable postoperative outcomes

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The objectives of the present study were to investigate the length change in different bundles of the superficial medial collateral ligament (sMCL) and lateral collateral ligament (LCL) during lunge, and to evaluate their association with Knee Society Score (KSS) following medial-pivot total knee arthroplasty (MP-TKA).

Methods

Patients with unilateral MP-TKA knees performed a bilateral single-leg lunge under dual fluoroscopy surveillance to determine the in-vivo six degrees-of-freedom knee kinematics. The contralateral non-operated knees were used as the control group. The attachment sites of the sMCL and LCL were marked to calculate the 3D wrapping length. The sMCL and LCL were divided into anterior, intermediate, and posterior portions (aMCL, iMCL, pMCL, aLCL, iLCL, pLCL). Correlations between lengths/elongation rate of ligament bundles from full extension to 100° flexion and the KSS were examined.

Results

The sMCL and LCL demonstrated relative stability in length at low flexion, but sMCL length decreased whereas LCL increased with further flexion on operated knees. The sMCL length increased at low flexion and remained stable with further flexion, while the LCL length decreased with flexion on the contralateral non-operated knees. The lengths of aMCL, iMCL, and pMCL showed moderate (0.5 < r < 0.7, p < 0.05) negative correlations with the KSS, and the lengths of aLCL, iLCL, and pLCL were positively correlated with the KSS at mid flexion on operated knees (p < 0.05). The elongation rates of aLCL, iLCL, and pLCL were negatively correlated with the KSS at high flexion on operated knees (p < 0.05). However, no significant correlations between the length of different bundles of sMCL or LCL with KSS were found on contralateral non-operated knees.

Conclusions

The elongation pattern of sMCL/LCL on MP-TKA knees showed differences with contralateral non-operated knees. The sMCL is tense at low to middle flexion and relaxed at high flexion, while LCL is relaxed at low to middle flexion and tense at high flexion following MP-TKA. Medial stability and proper lateral flexibility during mid flexion were associated with favorable postoperative outcomes in MP-TKA patients. In contrast, lateral relaxation at deep flexion should be avoided when applying soft-tissue balancing in MP-TKA.

Level of evidence

Level III.

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Data availability

The data that support the findings of this study are available from the corresponding author, [T-YT], upon reasonable request.

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Funding

This project was sponsored by the National Natural Science Foundation of China (31972924), the Science and Technology Commission of Shanghai Municipality ( 22S31906000), and the Pudong Science Technology and Economy Commission (210H1147900).

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Author notes

  1. Diyang Zou and Zhi Ling have contributed equally to this article.

Authors and Affiliations

  1. School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University; Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China

    Diyang Zou, Zhi Ling, Nan Zheng & Tsung-Yuan Tsai

  2. Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Diyang Zou, Zhi Ling, Nan Zheng & Tsung-Yuan Tsai

  3. Department of Orthopedics, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China

    Jiaqi Tan & Yunsu Chen

  4. Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, CH-8008, Zürich, Switzerland

    Dimitris Dimitriou

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  1. Diyang Zou
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Contributions

DZ and ZL made substantial contributions to the conception and design, acquisition and analysis, and interpretation of the data, were involved in drafting the manuscript and gave final approval of the version to be published. JT and NZ each partially helped in data acquisition and analysis. DD made contributions to the article revision. YC and TYT made contributions to data interpretation and study design. All authors contributed to the article and approved the submitted version.

Corresponding authors

Correspondence to Dimitris Dimitriou, Yunsu Chen or Tsung-Yuan Tsai.

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Ethical approval

Institution Review Board of Shanghai Sixth People’s Hospital: YS-2018–124.

Conflict of interest

TYT received research funding from MicroPort Orthopedics Inc.

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Zou, D., Ling, Z., Tan, J. et al. Medial stability and lateral flexibility of the collateral ligaments during mid-range flexion in medial-pivot total knee arthroplasty patients demonstrates favorable postoperative outcomes. Knee Surg Sports Traumatol Arthrosc 31, 3734–3744 (2023). https://doi.org/10.1007/s00167-023-07307-0

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