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Kanna R, Kumar VS, Karthikeyan V, Anand S, Ravichandran C, Murali SM. Influence of Preoperative Deformity on Flexion Gap Asymmetry in Measured Resection Technique: A Theoretical Study in Navigated Gap Balancing Total Knee Arthroplasties, Done for Varus Knee Osteoarthritis. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202402000-00007. [PMID: 38354198 PMCID: PMC11136515 DOI: 10.5435/jaaosglobal-d-23-00082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 11/15/2023] [Accepted: 12/07/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Disagreement exists on (a) achieving a symmetrical flexion gap and (b) the influence of varus deformity on the flexion gap asymmetry (FGA) in measured resection (MR) total knee arthroplasty (TKA). We aimed to determine the FGA and influence of preoperative deformity on the FGA, based on the MR technique, in varus knee osteoarthritis. METHODS In 321 navigated TKAs, we released the soft tissues in extension. In 90° flexion, with the tensioner in situ, we calculated the FGA, the angle between the posterior femoral cut (planned 3° external rotation to the posterior condylar line, parallel to the surgical transepicondylar axis, or perpendicular to the Whiteside line) and the proximal tibial resection plane. RESULTS The FGA values varied widely, and the risk of >2° and >3° FGA was present in at least 60% and 40% knees, respectively. These risks were high in knees with moderate and severe varus deformity. CONCLUSIONS In varus knee osteoarthritis, the risk of FGA (based on the MR technique) was high, especially when the deformity was moderate to severe. Caution is required in MR TKA, and surgeons must consider safer alternatives (gap balancing or hybrid technique) to achieve a symmetrical flexion gap in these knees.
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Affiliation(s)
- Raj Kanna
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - V. Senthil Kumar
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - Vijaya Karthikeyan
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - Sumit Anand
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - Chandramohan Ravichandran
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - S. M. Murali
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
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Dobbelaere A, Müller JH, Aït-Si-Selmi T, Gousopoulos L, Saffarini M, Bonnin MP. Sagittal femoral condylar shape varies along a continuum from spherical to ovoid: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2022; 143:3347-3361. [PMID: 36121475 DOI: 10.1007/s00402-022-04613-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/03/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Considerable anatomic variations of sagittal femoral condylar shape have been reported, with a continuum between spherical (or single-radius) and ovoid (or multi-radius) condyles. The purpose of this systematic review and meta-analysis was to critically appraise and synthesise the available literature on the sagittal femoral profile. The hypothesis was that studies would reveal considerable variability among individuals, but also in their methodology to quantify sagittal profiles. METHODS This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. On 10 September 2021 two authors searched for Level I to IV studies that reported on the sagittal curvature of the medial and/or lateral femoral condyles using the MEDLINE®, EMBASE® and Cochrane Library. Results were summarised by tabulating means, standard deviations and/or ranges for the reported radii-of-curvature, or ellipsoidal semi-major and semi-minor lengths of the condyles. To quantify sagittal 'ovoidicity' and asymmetry, results were stratified according to coordinate reference frame (posterior condylar axis (PCA), clinical and surgical transepicondylar axis (cTEA and sTEA), unified sagittal plane (USP), or unclear) and summarised in forest plots as standardised mean differences (SMD). RESULTS Thirty-eight articles were eligible for full text extraction, quantifying sagittal radii-of-curvature by best-fit circles (BFC), ellipsoids, polynomials, spherical or cylindrical fitting. Studies with clear definition of the measurement plane revealed that both condyles were generally ovoid, with considerably greater 'ovoidicity' at the medial condyle (SMD, 4.09) versus the lateral condyle (SMD, 3.33). In addition, distal condylar radii were greater medially when measured normal to the TEA (cTEA: SMD, 0.81; sTEA: SMD, 0.79), but greater laterally when measured in a USP (SMD, - 0.83). Posterior condylar radii were greater laterally when measured in a USP (SMD, - 0.60). CONCLUSION Studies reported considerable variability of sagittal femoral condylar radii-of-curvature, which are not incremental, but rather a continuum that ranges from spherical to ovoid. Although this variation could be accommodated by single-, dual- and multi-radii femoral components, a surgeon typically uses only one or two TKA designs. Hence, there is a risk of mismatch between the native and prosthetic sagittal profile that could result in mid-flexion ligament imbalance unless other parameters are changed. These findings support the drive towards patient-specific implants to potentially achieve accurate sagittal bone-implant fit through implant customisation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Andreas Dobbelaere
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, Ramsay Santé, Lyon, France
| | | | - Tarik Aït-Si-Selmi
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, Ramsay Santé, Lyon, France
| | - Lampros Gousopoulos
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, Ramsay Santé, Lyon, France
| | - Mo Saffarini
- ReSurg SA, Rue Saint-Jean 22, 1260, Nyon, Switzerland.
| | - Michel P Bonnin
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, Ramsay Santé, Lyon, France
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Mullaji A, Singh A, Haidermota M. Arthritic knees with more than 10° valgus can have soft-tissue imbalance in flexion. Knee Surg Sports Traumatol Arthrosc 2022; 30:2905-2914. [PMID: 34821942 DOI: 10.1007/s00167-021-06798-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/04/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Valgus knees have inferior outcomes compared to varus knees. There is little data regarding soft-tissue balance in flexion which may influence outcome in valgus knees undergoing TKA. The purpose of this study was to evaluate whether there is imbalance between medial and lateral flexion gaps in valgus deformity. A secondary aim was to compare soft-tissue balance in knees with valgus deformity less than 10° with those exceeding 10°. The null hypothesis was that there was no soft-tissue imbalance in 90° of flexion irrespective of magnitude of deformity. METHODS 64 valgus knees (52 female and 12 male) with deformity from 0.5 to 27.5° (mean 188.77, SD 6.21) were studied in 54 patients (mean age 67.81 y, SD 8.69) undergoing navigated TKA. Medial and lateral gaps in extension and at 90° of flexion were compared (using Independent-samples t test) between knees with valgus < 10° with those > 10° using a validated dynamic method after resection of cruciates, menisci and osteophytes, and then after final trialling. RESULTS Mean initial medial-lateral (ML) gap difference in extension was 2.63 mm (SD 2.63) and 2.09 mm (SD 3.78) in flexion, being tighter laterally. Initial ML gap differences in extension and flexion correlated with valgus deformity (R = - 0.514; p = 0.00001; R = - 0.325; p = 0.01, respectively). Initial ML gap differences in extension correlated with those in flexion (R = 0.42; p = 0.0005). Mean ML flexion and extension gap differences were 1.30 mm (SD 3.67) and 1.26 mm (SD 1.92) in knees with < 10° valgus, and 3.17 mm (SD 3.71) and 4.29 mm (SD 2.45) in those > 10° valgus; p values were 0.026 and < 0.001 respectively. CONCLUSION The lateral flexion gap in valgus knees may be narrower than the medial flexion gap, especially in knees with > 10° deformity. This contrasts with native and varus knees, in which it exceeds the medial gap. This novel study indicates the need to identify valgus knees with lateral flexion gap tightness by distracting the posterior femoral condyles from the proximal tibia by dynamic stressing of the soft-tissues after resection of cruciates, menisci, and osteophytes, with the knee flexed to 90°. These findings, highlighting the need for restoring flexion gap balance, may improve the inferior outcomes in valgus knees. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Arun Mullaji
- Breach Candy Hospital, Bhulabhai Desai Road, Mumbai, 400036, India. .,Mullaji Knee Clinic, Mumbai, 400036, India.
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Song SJ, Lee HW, Kim KI, Park CH. Appropriate determination of the surgical transepicondylar axis can be achieved following distal femur resection in navigation-assisted total knee arthroplasty. Knee Surg Relat Res 2021; 33:41. [PMID: 34758870 PMCID: PMC8579642 DOI: 10.1186/s43019-021-00123-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Many surgeons have determined the surgical transepicondylar axis (sTEA) after distal femur resection in total knee arthroplasty (TKA). However, in most navigation systems, the registration of the sTEA precedes the distal femur resection. This sequential difference can influence the accuracy of intraoperative determination for sTEA when considering the proximal location of the anatomical references for sTEA and the arthritic environment. We compared the accuracy and precision in determinations of the sTEA between before and after distal femur resection during navigation-assisted TKA. Methods Ninety TKAs with Attune posterior-stabilized prostheses were performed under imageless navigation. The sTEA was registered before distal femur resection, then reassessed and adjusted after distal resection. The femoral component was implanted finally according to the sTEA determined after distal femur resection. Computed tomography (CT) was performed postoperatively to analyze the true sTEA (the line connecting the tip of the lateral femoral epicondyle to the lowest point of the medial femoral epicondylar sulcus on axial CT images) and femoral component rotation (FCR) axis. The FCR angle after distal femur resection (FCRA-aR) was defined as the angle between the FCR axis and true sTEA on CT images. The FCR angle before distal resection (FCRA-bR) could be presumed to be the value of FCRA-aR minus the difference between the intraoperatively determined sTEAs before and after distal resection as indicated by the navigation system. It was considered that the FCRA-bR or FCRA-aR represented the differences between the sTEA determined before or after distal femur resection and the true sTEA, respectively. Results The FCRA-bR was −1.3 ± 2.4° and FCRA-aR was 0.3 ± 1.7° (p < 0.001). The range of FCRA-bR was from −6.6° to 4.1° and that of FCRA-aR was from −2.7° to 3.3°. The proportion of appropriate FCRA (≤ ±3°) was significantly higher after distal femur resection than that before resection (91.1% versus 70%; p < 0.001). Conclusions The FCR was more appropriate when the sTEA was determined after distal femur resection than before resection in navigation-assisted TKA. The reassessment and adjusted registration of sTEA after distal femur resection could improve the rotational alignment of the femoral component in navigation-assisted TKA. Level of evidence IV.
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Affiliation(s)
- Sang Jun Song
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 23 Kyunghee-daero, Dongdaemun-gu, Seoul, 130-872, South Korea
| | - Hyun Woo Lee
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 23 Kyunghee-daero, Dongdaemun-gu, Seoul, 130-872, South Korea
| | - Kang Il Kim
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 23 Kyunghee-daero, Dongdaemun-gu, Seoul, 130-872, South Korea
| | - Cheol Hee Park
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 23 Kyunghee-daero, Dongdaemun-gu, Seoul, 130-872, South Korea.
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Gao Q, Yao Y, Jing J. Morphological characteristics and clinical significance of the distal femur in patients with hemophilia-related knee arthritis. Medicine (Baltimore) 2020; 99:e22986. [PMID: 33217800 PMCID: PMC7676527 DOI: 10.1097/md.0000000000022986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This retrospective study aimed to define the morphological characteristics of the distal femur in patients with hemophilia-related knee arthritis (HA) and develop precise femoral component installation during total knee arthroplasty (TKA) using a reference axis.Computed tomography (CT) was performed in 75 patients [HA group: 34 patients, 48 knees; osteoarthritis (OA group): 41 patients, 48 knees] during 2017-2019. CT scans were constructed into three-dimensional models. We measured the medial (MPC) and lateral (LPC) posterior condyle widths, lateral anteroposterior (LAP) height, medial anteroposterior (MAP) height, mediolateral epicondyle (ML) width, and depths of the anterior patellar groove (X2) and the intercondylar notch (X4). Also, angles were measured between the posterior condylar line (PCL) and surgical transepicondylar axis (STEA) (PCA angle), anteroposterior axis (APA angle) and STEA (APSA angle), anterior condylar line (ACL) and STEA (ACA angle), and clinical transepicondylar axis (CTEA) and PCL (CTA angle). ML/MAP, ML/LAP, X4/LAP, X2/LAP, and LPC/ML ratios were calculated.There were no significant differences in any angles between the HA and OA groups (P > .05). However, the HA group had a smaller MPC (P < .05) and larger X4 than the OA group (P < .05). ML, ML/LAP, X2, MAP, and LAP showed no significant differences between the 2 groups.ML, ML/LAP, and PCA showed no significant differences between the 2 groups. During TKA in hemophilia-related knee arthritis patients, the femoral component can be installed with PCL as the reference axis, although individual differences should be considered.
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Small soft tissue tension changes do not affect patient-reported outcomes one year after primary TKA. INTERNATIONAL ORTHOPAEDICS 2020; 45:139-145. [PMID: 33040158 DOI: 10.1007/s00264-020-04839-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Adequate soft tissue tension and balance is paramount to achieve favourable outcomes of total knee arthroplasty (TKA). Implant manufacturers offer 1-mm liner increments to fine-tune ligament tension and balance. In this study, we assessed if soft tissue tension changes introduced by minimal changes in liner thicknesses affect early patient reported outcomes. METHODS Eighty-nine patients undergoing 99 primary, elective TKAs by a single surgeon were included. After achieving adequate ligament balance, the first 50 knees received an insert that would allow 2-3 mm of medial and lateral opening (control group), whereas the last 49 received an insert which was 1 mm thicker, resulting in a slight increase in ligament tension (study group). Sensor technology was used to record compartmental loads. Knee Society Score (KSS), KOOS Jr., and ROM were recorded pre-operatively, six weeks, four and 12 months post-operatively. The Forgotten Joint Score (FJS) was administered four and 12 months post-operatively. RESULTS No differences were observed in demographic variables, pre-operative outcome scores, and ROM measures between groups. Six weeks post-operatively, there was no statistically significant difference in the outcome variables. Four months post-operatively, statistically significant differences were only observed in KOOS Jr. (79 and 73.6; p = 0.05), and FJS (59.9 and 45.5; p < 0.01); all of which favoured the control group. There was no difference in the outcome variables at 12 months. CONCLUSION Minor changes in soft tissue tension induced by 1-mm changes in liner thickness resulted in clinically meaningful differences favouring the control group four months post-operatively, but in no clinically noticeable differences 12 months post-operatively. It is possible that lower soft tissue tension may lead to transient improvement in patient-reported early outcomes.
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