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Ball-in-socket medial conformity with posterior cruciate ligament retention neither limits internal tibial rotation and knee flexion nor lowers clinical outcome scores after unrestricted kinematically aligned total knee arthroplasty

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Abstract

Purpose

For a new tibial insert design with ball-in-socket (B-in-S) medial conformity (MC), posterior cruciate ligament (PCL) retention, and flat lateral articular surface (B-in-S MC + PCL), this study determined whether internal tibial rotation and knee flexion were limited and clinical outcome scores were lower during weight-bearing activities relative to an insert with intermediate (I) (i.e., less than ball-in-socket) medial conformity (I MC + PCL).

Methods

Twenty-five patients were treated with bilateral unrestricted, caliper-verified kinematic alignment (KA) total knee arthroplasty (TKA) with an I MC + PCL insert and B-in-S MC + PCL insert in opposite knees. Each patient performed weight-bearing deep knee bend, step up, and chair rise under single-plane fluoroscopy. Analysis following 3D model-to-2D image registration determined internal tibial rotation. For each TKA, knee flexion was measured and patients completed clinical outcome scoring questionnaires.

Results

Internal tibial rotation did not differ between conformities during chair rise and step up (p = 0.3419 and 0.1030, respectively). During deep knee bend, internal tibial rotation between 90° and maximum flexion was 3° greater in the B-in-S MC + PCL group (18° vs 15°) (p = 0.0290). Mean knee flexion (p = 0.3115) and median Forgotten Joint Score (FJS), Oxford Knee Score (OKS), and Western Ontario and McMasters Universities Arthritis Index (WOMAC) scores (p = 0.2100, 0.2154, and 0.4542, respectively) did not differ between conformities.

Conclusion

An insert with ball-in-socket medial conformity, which maximizes anteroposterior (AP) stability, did not limit internal tibial rotation and knee flexion and did not lower patient-reported outcomes when implanted with unrestricted caliper-verified KA and PCL retention. The high AP stability provided by the medial ball-in-socket might interest those surgeons exploring the treatment of the active patient with a desire to return to high-level and athletic activities.

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Funding

M. L. Hull received research support from Medacta USA, Inc. and the Orthopaedic Research and Education Foundation.

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Authors and Affiliations

  1. Department of Mechanical Engineering, University of California Davis, Davis, CA, 95616, USA

    Saúl Pacheco Elorza & Maury L. Hull

  2. Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, 95817, USA

    Ed O’Donnell & Maury L. Hull

  3. Adventist Lodi Memorial Medical Center, Lodi, CA, 95240, USA

    Alexander Nedopil

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

    Stephen M. Howell & Maury L. Hull

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  1. Saúl Pacheco Elorza
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Correspondence to Maury L. Hull.

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Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of the University of California Davis (IRB# 1385598–6).

Consent to participate

The text states that consent was obtained from all subjects who participated in the study.

Consent for publication

All authors contributed substantively to this study. Material preparation, data collection, and analysis were performed by S. P. Elorza, E. O’Donnell, and A. Nedopil. The first draft of the manuscript was written by S. P. Elorza. M. L. Hull and S. M. Howell extensively revised the first draft. All authors read and approved the final manuscript.

Conflict of interest

S. M. Howell receives royalties from Medacta and is a paid consultant for Medacta. M. L. Hull receives research support from Medacta USA, Inc. and from the Orthopaedic Research and Education Foundation. M. L. Hull is on the Editorial Board of the Journal of Biomechanics. E. O’Donnell owns stock in Novocure. A. Nedopil receives royalties and is a paid consultant for Medacta.

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Appendix

Appendix

Table 4 Recommended and default values for translations (xt, yt, zt) and rotations (xr, yr, zr) of the three stages of optimization for the registration software. The three stages are trunk, branch, and leaf. The zt range is greater than the xt and yt ranges in some cases because zt defines the out of plane direction and is prone to more error than the in-plane directions
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Elorza, S.P., O’Donnell, E., Nedopil, A. et al. Ball-in-socket medial conformity with posterior cruciate ligament retention neither limits internal tibial rotation and knee flexion nor lowers clinical outcome scores after unrestricted kinematically aligned total knee arthroplasty. International Orthopaedics (SICOT) 47, 1737–1746 (2023). https://doi.org/10.1007/s00264-023-05834-6

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