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Increases in tibial force imbalance but not changes in tibiofemoral laxities are caused by varus–valgus malalignment of the femoral component in kinematically aligned TKA

  • Knee
  • Published:
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 varus–valgus (V–V) malalignment of the femoral component in kinematically aligned total knee arthroplasty (TKA) and use the results to detemine sensitivities to errors in making the distal femoral resections. Because V–V malalignment would introduce the greatest changes in the alignment of the articular surfaces at 0° flexion, the hypotheses were that the greatest increases in tibial force imbalance would occur at 0° flexion, that primarily V–V laxity would significantly change at this flexion angle, and that the tibial force imbalance would increase and laxities would change in proportion to the degree of V–V malalignment.

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 V–V malalignments of 2° and 4° from the reference component. Medial and lateral tibial forces were measured during passive knee flexion–extension between 0° to 120° using a custom tibial force sensor. Eight laxities were measured from 0° to 120° flexion using a six degree-of-freedom load application system.

Results

With the tibial component kinematically aligned, the increase in the tibial force imbalance from that of the reference component at 0° of flexion was sensitive to the degree of V–V malalignment of the femoral component. Sensitivities were 54 N/deg (medial tibial force increasing > lateral tibial force) (p < 0.0024) and 44 N/deg (lateral tibial force increasing > medial tibial force) (p < 0.0077) for varus and valgus malalignments, respectively. Varus–valgus malalignment did not significantly change varus, internal–external rotation, anterior–posterior, and compression–distraction laxities from 0° to 120° flexion. At only 30° of flexion, 4° of varus malalignment increased valgus laxity 1° (p = 0.0014).

Conclusion

At 0° flexion, V–V malalignment of the femoral component caused the tibial force imbalance to increase significantly, whereas the laxities were relatively unaffected. Because tibial force imbalance has the potential to adversely affect patient-reported outcomes and satisfaction, surgeons should strive to limit errors in resecting the distal femoral condyles to within ± 0.5 mm which in turn limits the average increase in tibial force imbalance to 68 N. Because laxities were generally unaffected, instability resulting from large increases in laxity is not a clinical concern within the ± 4° range tested.

Level of evidence

Therapeutic, Level II.

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Authors and Affiliations

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

    Jeremy Riley & Joshua D. Roth

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

    Stephen M. Howell & Maury L. Hull

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

    Maury L. Hull

  4. Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA

    Maury L. Hull

Authors
  1. Jeremy Riley
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  2. Joshua D. Roth
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  3. Stephen M. Howell
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  4. Maury L. Hull
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Corresponding author

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., Howell, S.M. et al. Increases in tibial force imbalance but not changes in tibiofemoral laxities are caused by varus–valgus malalignment of the femoral component in kinematically aligned TKA. Knee Surg Sports Traumatol Arthrosc 26, 3238–3248 (2018). https://doi.org/10.1007/s00167-018-4841-6

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  • DOI: https://doi.org/10.1007/s00167-018-4841-6

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