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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
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purposes of this study were to quantify the increase in tibial force imbalance (i.e. magnitude of difference between medial and lateral tibial forces) and changes in laxities caused by  2° and 4° of internal–external (I–E) malalignment of the femoral component in kinematically aligned total knee arthroplasty. Because I–E malalignment would introduce the greatest changes to the articular surfaces near 90° of flexion, the hypotheses were that the tibial force imbalance would be significantly increased near 90° flexion and that primarily varus–valgus laxity would be affected near 90° flexion.

Methods

Kinematically aligned TKA was performed on ten human cadaveric knee specimens using disposable manual instruments without soft tissue release. One 3D-printed reference femoral component, with unmodified geometry, was aligned to restore the native distal and posterior femoral joint lines. Four 3D-printed femoral components, with modified geometry, introduced I–E malalignments of 2° and 4° from the reference component. Medial and lateral tibial forces were measured from 0° to 120° flexion using a custom tibial force sensor. Bidirectional laxities in four degrees of freedom were measured from 0° to 120° flexion using a custom load application system.

Results

Tibial force imbalance increased the greatest at 60° flexion where a regression analysis against the degree of I–E malalignment yielded sensitivities (i.e. slopes) of 30 N/° (medial tibial force > lateral tibial force) and 10 N/° (lateral tibial force > medial tibial force) for internal and external malalignments, respectively. Valgus laxity increased significantly with the 4° external component with the greatest increase of 1.5° occurring at 90° flexion (p < 0.0001).

Conclusion

With the tibial component correctly aligned, I–E malalignment of the femoral component caused significant increases in tibial force imbalance. Minimizing I–E malalignment lowers the increase in the tibial force imbalance. By keeping the resection thickness of each posterior femoral condyle to within ± 0.5 mm of the thickness of the respective posterior region of the femoral component, the increase in imbalance can be effectively limited to 38 N. Generally laxities were unaffected within the ± 4º range tested indicating that instability is not a clinical concern and that manual testing of laxities is not useful to detect I–E malalignment.

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Acknowledgements

The authors acknowledge the support of the National Science Foundation (Grant no. CBET-1067527) and Zimmer Biomet, Inc. (Grant no. CW874).

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Authors and Affiliations

  1. Biomedical Engineering Graduate Group, University of California, Davis, USA

    Jeremy Riley & Joshua D. Roth

  2. Department of Biomedical Engineering, University of California, Davis, USA

    Stephen M. Howell & Maury L. Hull

  3. Department of Mechanical Engineering, University of California, Davis, USA

    Maury L. Hull

  4. Department of Orthopaedic Surgery, University of California, Davis, USA

    Maury L. Hull

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  1. Jeremy Riley
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  2. Joshua D. Roth
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  4. Maury L. Hull
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Correspondence to Maury L. Hull.

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Conflict of interest

J. D. Roth has a postdoctoral fellowship from Think Surgical, S. M. Howell is a paid consultant for Think Surgical and Medacta and receives royalties from Zimmer-Biomet. M. L. Hull receives research funding from Zimmer-Biomet.

Funding

The authors acknowledge the support of the National Science Foundation (Grant No. CBET-1067527) and support of Zimmer (Award No. CW88095).

Ethical approval

The cadaveric specimens were obtained through the UC Davis Donated Body Program and were approved for use by this program. The authors would like to thank individuals who donate their remains and tissues for the advancement of education and research.

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Riley, J., Roth, J.D., Howell, S.M. et al. 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, 1618–1628 (2018). https://doi.org/10.1007/s00167-017-4776-3

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