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Comparable accuracy of femoral joint line reconstruction in different kinematic and functional alignment techniques

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

Abstract

Purpose

A key part of kinematic alignment (KA) and functional alignment (FA) is to restore the natural femoral joint line, in particular the medial joint line. KA is known to reproduce the femoral joint line accurately; however, direct comparisons with other surgical techniques such as FA are currently lacking. The purpose of this study was to evaluate differences of alignment parameters in KA and FA techniques with a special focus given to the femoral joint line.

Methods

We performed a retrospective radiological analysis of pre- and postoperative long leg radiographs of 221 consecutive patients with varus or neutral leg alignment, who underwent primary total knee arthroplasty (TKA) procedures from 2018 to 2020. Patients were assigned to one of four groups: (1) FA: image-based robotic-assisted TKA, (2) FA: imageless robotic-assisted TKA, (3): restricted KA: 3D cutting block-assisted (patient-specific instruments, PSI) TKA, (4): unrestricted KA: calipered technique. Patients’ radiographs were (re)-analyzed for overall limb alignment, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), as well as medial and lateral femoral joint line alteration. Statistical significance was determined using unpaired t testing (FA vs. KA group) and one-way ANOVA (subgroup analyses).

Results

Comparisons of KA vs. FA, as well as individual subgroups of KA and FA did not show any differences in the accuracy of medial joint line reconstruction (< 2 mm, p = 0.384, p = 0.744, respectively) and LDFA alteration (< 2°, p = 0.997, 0.921, respectively). Correction of MPTA (3.4° vs. 2.2°) and lateral femoral joint line (2.1 mm vs. 1.5 mm) was higher for FA and FA subgroups compared to KA and KA subgroups (both p < 0.001).

Conclusion

Kinematic and functional alignments showed a comparable accuracy in reconstruction of the medial femoral joint line and femoral joint line orientation. Increased correction of MPTA and lateral femoral joint line was recorded with FA techniques.

Level of evidence

III.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

aHKA:

Arithmetic hip-to-knee angle

AT:

Adductor tubercle

ATJL:

Adductor tubercle joint line distance

BCS:

Bi-cruciate stabilized

CT:

Computed tomography

FA:

Functional alignment

HKA:

Hip-to-knee angle

JL:

Joint line

JLO:

Joint line obliquity

KA:

Kinematic alignment

LDFA:

Lateral distal femoral angle

lJL:

Lateral femoral joint line

mJL:

Medial femoral joint line

MPTA:

Medial proximal tibial angle

OLA:

Overall limb alignment

PSI:

Patient-specific instruments

PS:

Posterior stabilized

rTKA:

Robotic-assisted total knee arthroplasty

SD:

Standard deviation

TKA:

Total knee arthroplasty

References

  1. Agrawal VO, Gadekar AP, Vaidya N (2022) Does robotic technology successfully restore the joint line after total knee arthroplasty? A retrospective analysis. Arthroplasty 4:6

    Article  PubMed  PubMed Central  Google Scholar 

  2. Chang JS, Kayani B, Wallace C, Haddad FS (2021) Functional alignment achieves soft-tissue balance in total knee arthroplasty as measured with quantitative sensor-guided technology. Bone Jt J 103-B:507–514

    Article  Google Scholar 

  3. D’Amato M, Kosse NM, Wymenga AB (2021) Restoration of pre-operative joint line orientation and alignment does not affect KSS and KOOS 1 year after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 29:3170–3177

    Article  PubMed  Google Scholar 

  4. Eckhoff D, Hogan C, DiMatteo L, Robinson M, Bach J (2007) An ABJS BEST PAPER: difference between the epicondylar and cylindrical axis of the knee. Clin Orthop 461:238–244

    Article  PubMed  Google Scholar 

  5. Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG (1993) The axes of rotation of the knee. Clin Orthop 290:259–268

    Article  Google Scholar 

  6. Howell SM (2019) Calipered kinematically aligned total knee arthroplasty: an accurate technique that improves patient outcomes and implant survival. Orthopedics 42:126–135

    Article  PubMed  Google Scholar 

  7. Howell SM, Nedopil AJ, Hull ML (2022) Negligible effect of surgeon experience on the accuracy and time to perform unrestricted caliper verified kinematically aligned TKA with manual instruments. Knee Surg Sports Traumatol Arthrosc 30:2966–2974

    Article  PubMed  PubMed Central  Google Scholar 

  8. Kayani B, Konan S, Ayuob A, Onochie E, Al-Jabri T, Haddad FS (2019) Robotic technology in total knee arthroplasty: a systematic review. EFORT Open Rev 4:611–617

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kim J-T, Han J, Lim S, Shen QH, Won YY (2019) Kinematically aligned TKA aligns the ankle joint line closer to those of the native ankle than mechanically aligned TKA in bipedal stance. J Knee Surg 32:1033–1038

    Article  PubMed  Google Scholar 

  10. Li G, Park SE, DeFrate LE, Schutzer ME, Ji L, Gill TJ, Rubash HE (2005) The cartilage thickness distribution in the tibiofemoral joint and its correlation with cartilage-to-cartilage contact. Clin Biomech Bristol Avon 20:736–744

    Article  PubMed  Google Scholar 

  11. Liow MHL, Xia Z, Wong MK, Tay KJ, Yeo SJ, Chin PL (2014) Robot-assisted total knee arthroplasty accurately restores the joint line and mechanical axis. A prospective randomised study. J Arthroplasty 29:2373–2377

    Article  PubMed  Google Scholar 

  12. Luyckx T, Vandenneucker H, Ing LS, Vereecke E, Ing AV, Victor J (2018) Raising the joint line in TKA is associated with mid-flexion laxity: a study in cadaver knees. Clin Orthop 476:601–611

    Article  PubMed  PubMed Central  Google Scholar 

  13. MacDessi SJ, Griffiths-Jones W, Harris IA, Bellemans J, Chen DB (2021) Coronal plane alignment of the knee (CPAK) classification: a new system for describing knee phenotypes. Bone Jt J 103-B:329–337

    Article  Google Scholar 

  14. Nedopil AJ, Howell SM, Hull ML (2020) Deviations in femoral joint lines using calipered kinematically aligned TKA from virtually planned joint lines are small and do not affect clinical outcomes. Knee Surg Sports Traumatol Arthrosc 28:3118–3127

    Article  PubMed  Google Scholar 

  15. Niki Y, Nagura T, Nagai K, Kobayashi S, Harato K (2018) Kinematically aligned total knee arthroplasty reduces knee adduction moment more than mechanically aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 26:1629–1635

    Article  PubMed  Google Scholar 

  16. Oussedik S, Abdel MP, Victor J, Pagnano MW, Haddad FS (2020) Alignment in total knee arthroplasty: what’s in a name? Bone Jt J 102-B:276–279

    Article  Google Scholar 

  17. Rivière C, Harman C, Boughton O, Cobb J (2020) The kinematic alignment technique for total knee arthroplasty. In: Rivière C, Vendittoli P-A (eds) Pers hip knee jt replace. Springer International Publishing, Cham, pp 175–195

    Chapter  Google Scholar 

  18. Rivière C, Iranpour F, Harris S, Auvinet E, Aframian A, Chabrand P, Cobb J (2017) The kinematic alignment technique for TKA reliably aligns the femoral component with the cylindrical axis. Orthop Traumatol Surg Res 103:1069–1073

    Article  PubMed  Google Scholar 

  19. Sappey-Marinier E, Batailler C, Swan J, Schmidt A, Cheze L, MacDessi SJ, Servien E, Lustig S (2021) Mechanical alignment for primary TKA may change both knee phenotype and joint line obliquity without influencing clinical outcomes: a study comparing restored and unrestored joint line obliquity. Knee Surg Sports Traumatol Arthrosc 30:2806–2814

    Article  PubMed  Google Scholar 

  20. Shah RF, Martinez AM, Pedoia V, Majumdar S, Vail TP, Bini SA (2019) Variation in the thickness of knee cartilage. The use of a novel machine learning algorithm for cartilage segmentation of magnetic resonance images. J Arthroplasty 34:2210–2215

    Article  PubMed  PubMed Central  Google Scholar 

  21. Shatrov J, Battelier C, Sappey-Marinier E, Gunst S, Servien E, Lustig S (2022) Functional alignment philosophy in total knee arthroplasty—rationale and technique for the varus morphotype using a CT based robotic platform and individualized planning. SICOT-J 8:11

    Article  PubMed  PubMed Central  Google Scholar 

  22. Shepherd DET, Seedhom BB (1999) Thickness of human articular cartilage in joints of the lower limb. Ann Rheum Dis 58:27–34

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Tuecking L-R, Ettinger M, Nebel D, Welke B, Schwarze M, Windhagen H, Savov P (2021) 3D-surface scan based validated new measurement technique of femoral joint line reconstruction in total knee arthroplasty. J Exp Orthop 8:16

    Article  PubMed  PubMed Central  Google Scholar 

  24. Vaidya NV, Deshpande AN, Panjwani T, Patil R, Jaysingani T, Patil P (2020) Robotic-assisted TKA leads to a better prosthesis alignment and a better joint line restoration as compared to conventional TKA: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 30:621–626

    Article  PubMed  Google Scholar 

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Acknowledgements

We thank Felix KF Kommoss for English language editing of the current manuscript.

Funding

This research received no external funding.

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Author notes

  1. Peter Savov & Max Ettinger

    Present address: Department of Orthopaedic and Trauma Surgery, Pius Hospital, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna Von Borries Str. 1-6, 30625, Hannover, Germany

    Lars-Rene Tuecking, Peter Savov, Mats Zander, Henning Windhagen & Max Ettinger

  2. Department of Orthopaedic Surgery, St.Vincenz Hospital Brakel, Danziger Str. 17, 33034, Brakel, Germany

    Dragan Jeremic

Authors
  1. Lars-Rene Tuecking
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Contributions

Conceptualization, L-RT, PS, HW and ME; data curation, MZ, L-RT, PS; formal analysis, L-RT, HW and ME; investigation, MZ, L-RT, PS; methodology, L-RT, MZ, PS, HW and ME; project administration, HW and ME; supervision, ME; visualization, PS; writing—original draft, L-RT; writing—review and editing, PS, DJ, HW and ME.

Corresponding author

Correspondence to Lars-Rene Tuecking.

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Conflict of interest

LT, PS, ME and HW are paid educational consultants for Stryker. LT, PS and ME are paid educational consultants for Smith & Nephew. HW is a paid consultant for Medacta. No funding was received for this study. MZ and DJ have no conflict of interest.

Ethical approval

This study was approved by the local ethics committee (8403_BO_S_2019).

Informed consent

Informed consent was not needed due to the use of only anonymized data (radiographs) in this retrospective study.

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Tuecking, LR., Savov, P., Zander, M. et al. Comparable accuracy of femoral joint line reconstruction in different kinematic and functional alignment techniques. Knee Surg Sports Traumatol Arthrosc 31, 3871–3879 (2023). https://doi.org/10.1007/s00167-023-07360-9

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  • DOI: https://doi.org/10.1007/s00167-023-07360-9

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