Reoperations are few and confined to the most valgus phenotypes 4 years after unrestricted calipered kinematically aligned TKA

Kinematic alignment adequately restores trochlear anatomy, patellar kinematics and kinetics in total knee arthroplasty: A systematic review

PURPOSE

Patellofemoral pain, maltracking and instability remain common and challenging complications after total knee arthroplasty. Controversy exists regarding the effect of kinematic alignment on the patellofemoral joint, as it generally leads to more femoral component valgus and internal rotation compared to mechanical alignment. The aim of this systematic review is to thoroughly examine the influence of kinematic alignment on the third space.

METHODS

A systematic search of the Pubmed, Cochrane and Web of Science databases was performed to screen for relevant articles published before 7 April 2024. This led to the final inclusion of 42 articles: 2 cadaveric, 9 radiographic, 12 computer simulation and 19 clinical studies. The risk of bias was evaluated with the risk of bias in non-randomised studies - of interventions tool as the lowest level of evidence of the included clinical studies was IV. The effects of kinematic alignment on patellar kinematics and kinetics, trochlear anatomy reconstruction and patellofemoral complication rate were investigated.

RESULTS

Kinematic alignment closely restores native patellar kinematics and kinetics, better reproduces native trochlear anatomy than mechanical alignment and leads to a 0%-11.4% incidence of patellofemoral complications. A more valgus joint line of the distal femur can cause lateral trochlear undercoverage and a trochlear angle orientation medial to the quadriceps vector when applying kinematic alignment, both of which can be solved by using an adjusted design with a 20.5° valgus trochlea.

CONCLUSION

Kinematic alignment appears to be a safe strategy for the patellofemoral joint in most knees, provided that certain precautions are taken to minimize the risk of complications.

LEVEL OF EVIDENCE

Level IV clinical studies, in vitro research.

Kinematical alignment better restores native patellar tracking pattern than mechanical alignment

PURPOSE

The purpose of this study was to assess whether kinematic alignment (KA) outperforms mechanical alignment (MA) in restoring patellar tracking to native patterns by using a clustering algorithm.

METHODS

Twenty cadavers (40 knees) were evaluated. For each cadaver, one knee was randomly assigned to KA and the other to MA. KA total knee arthroplasty (TKA) procedures were performed using a caliper-verified technique, while MA TKA procedures utilized a measured resection technique. Subsequently, all specimens were mounted on a customized knee-testing system, and patellar tracking was measured using a motion analysis system. All patellar tracking data were clustered using the density-based spatial clustering of applications with noise algorithm. Differences in patellar tracking patterns and the restoration of native patellar tracking were compared between the two alignment strategies.

RESULTS

Patellar tracking patterns following KA were considerably different from MA. Pre- and post-TKA patellar tracking patterns following MA were grouped into separate clusters, whereas a substantial proportion of patellar tracking patterns following KA were grouped into the pre-TKA dominant cluster. Compared to MA, a greater proportion of patellar tracking patterns following KA showed similar patterns to native knees (p < 0.05) and more patellar tracking patterns following KA paired with preoperative patterns (p < 0.01).

CONCLUSION

KA restored native patellar tracking patterns more closely compared to MA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Superiority of kinematic alignment over mechanical alignment in total knee arthroplasty during medium- to long-term follow-up: A meta-analysis and trial sequential analysis

PURPOSE

To compare and determine the reliability and conclusiveness of the medium- and long-term efficacy in terms of patient-reported outcome measures and the risk of revisions or reoperations (RRRs) of kinematic alignment (KA) and mechanical alignment (MA) in total knee arthroplasty.

METHODS

A comprehensive search was conducted in Medline, EMBASE, Web of Science and Cochrane Database Library to identify relevant literature. Only randomised clinical trials (RCTs) published before July 2023 were included. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Forgotten Joint Score (FJS) and RRR were compared. Additionally, OKS and RRR were subjected to a trial sequential analysis.

RESULTS

Seven RCTs involving 572 knees were identified. The pooled analysis of the included studies demonstrated that KA showed better medium-term WOMAC and OKS (mean difference [MD] = -6.3, 95% confidence interval [CI]: -9.52 to -2.99, p < 0.05 and MD = 1.1, 95% CI: 0.05-2.15, p < 0.05), respectively), but no significant differences were observed in the long-term follow-up (MD = 2.1, 95% CI: -3.21 to 7.31, not significant [n.s.] and MD = 0.01, 95% CI: -2.43 to 2.46, n.s., respectively). FJS (standardised MD = -0.03, 95% CI: -0.25 to 0.19, n.s.) and RRR (risk ratio = 1.0, 95% CI: 0.57 to 1.74, n.s.) showed no significant intergroup differences (n.s.). The evidence quality ranged from moderate to high, and the trial sequential analysis indicated the need for additional high-quality RCTs to draw more conclusive results.

CONCLUSIONS

KA showed better medium-term WOMAC and OKS, while KA and MA had similar FJS without increasing the RRR in medium- and long-term follow-up. Further research is needed for more conclusive results.

LEVEL OF EVIDENCE

Level II (meta-analyses).

Phenotype-considered kinematically aligned total knee arthroplasty for windswept-deformity-associated osteoarthritis: surgical strategy and clinical outcomes

BACKGROUND

Windswept deformity (WSD) in relation to advanced osteoarthritis (OA) presents a significant surgical challenge in total knee arthroplasty (TKA). The primary goal of this study is to investigate the Prevalance of WSD associated osteoarthritis who have undergone total knee arthroplasty. The secondary goal is to explore the causes of WSD and its association with spinal deformity or leg length discrepancy in these patients. Finally, we evaluate the surgical outcomes of phenotype-considered kinematically aligned TKA (KA-TKA) in treating patients with WSD.

METHODS

A review was conducted on data from 40 knees of 33 WSD patients who underwent phenotype-considered KA-TKA from August 2016 to December 2020. Patient demographics, associated diseases, preoperative and postoperative knee alignment angles, range of motion (ROM), Oxford Knee Score (OKS), and Knee Society Score (KSS) were collected and analyzed. Subgroup analysis for comparing the results between valgus and varus knees were also performed.

RESULTS

Within the studied cohort of WSD patients, a substantial 64% displayed concomitant coronal spinal imbalance and 21% evidenced leg length discrepancy. Postoperative improvements were notable in knee alignments, ROM, OKS, and KSS following the application of the phenotype-considered KA-TKA approach. There were significant differences in the knee alignment angles, including mHKA, LDFA, and MPTA, between the valgus and varus side of knees (P = 0.018). However, no statistically significant difference were observed in the functional scores, comprising ROM, OKS, and KSS, between valgus and varus knees.

CONCLUSIONS

A high percentage of patients with WSD exhibited coronal spinal imbalance and leg length discrepancy. Phenotype-considered KA-TKA effectively provided alignment targets for the treatment of both varus and valgus knees in patients with WSD, achieving excellent short-term outcomes and acceptable knee alignment.

Which method for femoral component sizing when performing kinematic alignment TKA? An in silico study

INTRODUCTION

The kinematically alignment (KA) technique for TKA aims to reproduce the pre-arthritic knee anatomy, including both the femoro-tibial and femoro-patellar joints. An in silico study was conducted to compare 3 different femoral component sizing techniques to identify the anatomical landmark which allows closest restoration of the native trochlear anatomy. Our study's question was: what was the best method for sizing the femoral component when performing KA-TKA? It was hypothesized that sizing the femoral component by aiming to restore the groove height would be the best method to restore the native trochlear anatomy.

METHODS

GMK sphere® (Medacta) femoral component 3D models were virtually kinematically aligned on 30 tri-dimensional (3D) bony osteoarthritis knee models. The femoral component was mediolaterally positioned to match distal native and prosthetic grooves. Three methods were used to size the femoral component: a conventional method with the anterior femoral cut flush to the femoral cortex (C-KATKA) and two alternative personalized methods aiming to recreate either the medial facet's height (ATM-KATKA) or the groove's height (ATG-KATKA). In-house analysis software was used to compare native and prosthetic trochlear articular surfaces and mediolateral implant overhangs.

RESULTS

Compared with the C-KATKA, ATG-KATKA and ATM-KATKA techniques increased the component size by a mean of 0.90 (SD 0.31, min 0.5 to max 1.5) (p<0.001) and 1.02 (SD 0.31, min 0.5 to max 1.5) (p<0.001), respectively. C-KATKA technique substantially proximally understuffed the trochleae with maximum values of 7.11mm (SD 1.39, min 3.93mm to max 10.57mm) in the medial facet, 4.72mm (SD 1.27, min 1.46mm to max 6.86mm) in the lateral facet and 4.51mm (SD 1.40, min 1.92mm to max 7.30mm) in the groove, respectively. Alternative techniques understuffed medial facet with maximum values of 5.07mm (SD 1.29, min 2.83mm to max 8.34mm) and 4.70mm (SD 1.52, min 0.83mm to max 8.04mm) for ATG-KATKA and ATM-KATKA techniques, respectively. There was no significant understuffing of the groove or lateral facet for alternative techniques (ATM and ATG). The ATM-KATKA and ATG-KATKA techniques generated mediolateral implant overhang, mainly postero-lateral, with a rate of 90.0% and 86.7%, respectively. In this study, no mediolateral implant overhang was found for C-KATKA.

DISCUSSION/CONCLUSION

The C-KATKA technique substantially understuffs the native trochlear articular surfaces in medial, lateral and groove parts. Alternative techniques (ATM-KATKA and ATG-KATKA) for sizing the femoral component better restore the native trochlear anatomy but also generate a high rate of postero-lateral implant overhangs. Would this postero-lateral implant overhang be clinically deleterious remains unknown? The aspect ratio of contemporary femoral TKA implants can probably be optimized to allow a better anatomical restoration of the anterior femoral compartment.

LEVEL OF EVIDENCE

II, in silico study.

Effectiveness of Kinematic Alignment-Total Knee Arthroplasty in Treating Preoperative Varus and Valgus Deformities in Patients With Knee Osteoarthritis

Knee osteoarthritis (OA) is surgically treated with total knee arthroplasty (TKA). Traditionally, TKA has been performed using a mechanical alignment (MA) philosophy. However, due to significant patient dissatisfaction with surgical outcomes, an alternate alignment approach, kinematic alignment (KA), has gained popularity. KA-TKAs have improved functional patient outcomes by restoring the patient's native joint line orientation and minimizing soft tissue releases compared to neutral alignment in MA-TKAs. This review explores the postoperative effectiveness of utilizing KA-TKA to treat knee OA in patients with preoperative varus and valgus deformities. A comprehensive literature search was conducted on PubMed and Biomed Central databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search focused on studies analyzing the postoperative TKA outcomes in knee OA patients with preoperative varus or valgus deformities whose surgeries followed a KA philosophy and those comparing KA-TKA with MA-TKA. The available clinical evidence indicates that KA-TKA can be a viable treatment option for individuals with knee OA. The alignment of phenotypes has little clinical significance concerning functional outcomes and implant survival rates following KA-TKA. Furthermore, surgery outcomes in patients with preoperative deformities who underwent KA-TKA were similar to those who underwent MA-TKA. KA-TKA produced significantly better functional outcomes than MA-TKA in certain aspects. However, studies with larger sample sizes and more extended follow-up periods that directly compare KA-TKA with MA-TKA in treating knee OA patients are needed to fully demonstrate the efficacy of each technique. Furthermore, further research into the effects of KA-TKA on implant survival rates will provide a better understanding of the benefits of this technique and ultimately lead to improved patient outcomes.

Better forgotten joint scores when the angle of the prosthetic trochlea is lateral to the quadriceps vector in kinematically aligned total knee arthroplasty

PURPOSE

The primary aim was to analyze unrestricted kinematic alignment (unKA) total knee arthroplasty (TKA) and determine the frequency of medial deviation of the prosthetic trochlear angle (PTA) of the femoral component relative to the quadriceps vector (QV) that terminates at the anterior inferior iliac spine (AIIS), and whether patients with medial deviation had a worse Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) relative to those with lateral deviation. The secondary aim was to determine the frequency of medial deviation for mechanical alignment (MA) TKA simulations.

METHODS

From a database of a single surgeon, the study extracted de-identified data on 147 patients with a CT scanogram showing the pelvis and AIIS, a limb with an unKA TKA, and a native (i.e., healthy) opposite limb. On the scanogram, an examiner, blinded to the PROMs, measured the PTA-QV angle on the unKA TKA and on the opposite limb simulated MA TKA by drawing the PTA at 6° valgus relative to the femoral mechanical axis and measuring the PTA-QV angle.

RESULTS

Medial deviation of the PTA occurred in 86% of patients with unKA TKA, and the 126 with medial deviation had a 17/1 point worse median FJS/OKS than the 21 with lateral deviation at a mean follow-up of 47 ± 8 months, respectively (p < 0.0001, p = 0.0053). In addition, 21%, 17%, and 8% of MA TKA had medial deviation after radiographic simulation using reported surgical errors for manual, patient-specific, and robotic instrumentation, respectively.

CONCLUSION

In most patients with unKA TKA and a smaller proportion with MA TKA, a PTA of 6° valgus was medial to the QV, which, by excluding the patient's Q-angle, might alter patellofemoral kinematics like an incorrectly oriented trochleoplasty. The 17-point worse FJS in the patients with an unKA TKA and medial deviation of the PTA suggests the surgical target should be to orient the PTA lateral to the QV.

LEVEL OF EVIDENCE

IV.

Influence of Mechanical Alignment on Functional Knee Phenotypes and Clinical Outcomes in Primary TKA: A 1-Year Prospective Analysis

In total knee arthroplasty (TKA), functional knee phenotypes are of interest regarding surgical alignment strategies. Functional knee phenotypes were introduced in 2019 and consist of limb, femoral, and tibial phenotypes. The hypothesis of this study was that mechanically aligned (MA) TKA changes preoperative functional phenotypes, which decreases the 1-year Forgotten Joint (FJS) and Oxford Knee Score (OKS) and increases the 1-year WOMAC. All patients included in this study had end-stage osteoarthritis and were treated with a primary MA TKA, which was supervised by four academic knee arthroplasty specialists. To determine the limb, femoral, and tibial phenotype, a long-leg radiograph (LLR) was imaged preoperatively and two to three days after TKA. FJS, OKS, and WOMAC were obtained 1 year after TKA. Patients were categorized using the change in functional limb, femoral, and tibial phenotype measured on LLR, and the scores were compared between the different categories. A complete dataset of preoperative and postoperative scores and radiographic images could be obtained for 59 patients. 42% of these patients had a change of limb phenotype, 41% a change of femoral phenotype, and 24% a change of tibial phenotype of more than ±1 relative to the preoperative phenotype. Patients with more than ±1 change of limb phenotype had significantly lower median FJS (27 points) and OKS (31 points) and higher WOMAC scores (30 points) relative to the 59-, 41-, and 4-point scores of those with a 0 ± 1 change (p < 0.0001 to 0.0048). Patients with a more than ±1 change of femoral phenotype had significantly lower median FJS (28 points) and OKS (32 points) and higher WOMAC scores (24 points) relative to the 69-, 40-, and 8-point scores of those with a 0 ± 1 change (p < 0.0001). A change in tibial phenotype had no effect on the FJS, OKS, and WOMAC scores. Surgeons performing MA TKA could consider limiting coronal alignment corrections of the limb and femoral joint line to within one phenotype to reduce the risk of low patient-reported satisfaction and function at 1-year.

Correcting for distal femoral asymmetry is necessary to determine postoperative alignment deviations from planned alignment of the femoral component

BACKGROUND

One method for assessing the accuracy of manual, patient-specific, navigational, and robotic-assisted total knee arthroplasty (TKA) instrumentation is to use a post-operative computer tomogram and determine the deviation of the femoral component alignment relative to the planned alignment in the native (i.e. healthy) contralateral distal femoral epiphysis. However, side-to-side asymmetry might introduce errors which inflate alignment deviations. This study quantified asymmetry in the distal femoral epiphysis.

METHODS

High resolution CT images (0.5 mm slice thickness) were acquired from bilateral lower limb specimens of 13 skeletally mature subjects with no skeletal abnormalities. Images were segmented to generate 3D femur models. Asymmetry was quantified by differences in positions and orientations required to shape-match the distal epiphysis of the mirror 3D femur model to the distal epiphysis of the contralateral 3D femur model.

RESULTS

Asymmetry was due to random rather than systematic differences. Random differences (i.e. standard deviations) in proximal-distal (P-D) and anterior-posterior (A-P) positions were 1.1 mm and in varus-valgus (V-V) and internal-external (I-E) orientations were 0.9° and 1.3°, respectively. These represented substantial relative errors of up to 50 % in previously reported overall alignment deviations.

CONCLUSIONS

Although small in an absolute sense, asymmetry of the distal femur epiphysis introduced substantial relative errors when assessing accuracy of femoral component alignment in TKA. When post-operative computer tomograms are used to assess the accuracy of manual, patient specific, navigational, and robotic-assisted TKA instrumentation, the overall deviation should be corrected for asymmetry to better indicate the accuracy of the surgical technique.

Coronal alignment classes after robotic-assisted total knee arthroplasty are not associated with variation in patient-reported outcome measurements: A single-center cohort study

BACKGROUND

The aims of this study were (1) to use three-dimensional computed tomography (3DCT) measurements to determine whether patients undergoing imageless robotic-assisted total knee arthroplasty (RA-TKA) develop a variety of postoperative distal femoral mechanical angle (FMA), proximal tibial mechanical angle (TMA), and hip-knee-ankle angle (HKA) phenotypes as described by Hirschmann et al, and (2) to compare postoperative patient-reported outcome measurements (PROMs) between these phenotypes.

METHOD

Fifty patients with knee osteoarthritis underwent RA-TKA. All surgeries were performed using bicruciate-stabilized TKA. In each case, the postoperative HKA, FMA and TMA were classified into one of Hirschmann's five FMA, five TMA, and seven HKA phenotype categories. We investigated how these phenotypes affected patient satisfaction, 2011 Knee Society Score (KSS) subscale scores, the Forgotten Joint Score-12 (FJS-12) score, and patella scores with anterior knee pain at a mean of 15.1 months after RA-TKA.

RESULTS

Coronal alignment angles were assigned to three FMA, four TMA, and five HKA phenotypes. The most common FMA, TMA, and HKA phenotypes were valgus FMA 3° (58%), valgus TMA 3° (60%), and varus HKA 3° (38%). The FMA, TMA, and HKA phenotypes showed no significant differences in any PROMs.

CONCLUSIONS

RA-TKA led to various HKA, FMA and TMA phenotypes in the coronal plane, none of which affected PROMs.

Alignment philosophy influences trochlea recreation in total knee arthroplasty: a comparative study using image-based robotic technology

PURPOSE

The ability of kinematic alignment (KA) to consistently restore trochlea anatomy in total knee arthroplasty (TKA) is unknown despite recreation of constitutional anatomy being its rationale for use. The purpose of this study was to assess if alignment choice in TKA effects the ability to restore the native trochlea groove.

METHODS

One hundred and twenty-two consecutive patients undergoing robotic-assisted TKA using the MAKO image-based robotic platform had simulated femoral components placed according to kinematic, mechanical and functional alignment principals. Implant position and trochlea restoration between groups were compared. Restoration was assessed by shift (medial-lateral) and depth relative to the native groove from three consistent points; full extension (0°), mid-flexion (30°-40°) and deep flexion (70°-80°).

RESULTS

Three hundred and sixty-six alignment options were analysed. Femoral alignment was significantly different between groups. Of KA, 13.1% compared to 3.3% of FA plans were outside safe coronal boundaries. The trochlear groove was translated the most by MA compared to KA and FA (full extension, MA 7.84 ± 1.99 mm lateral to the native groove, KA 6.40 ± 2.43 mm and FA 6.88 ± 1.74 mm, p ≤ 0.001). In full extension, FA most closely restored the trochlear groove depth in all three positions of flexion.

CONCLUSION

Alignment philosophy led to significant differences in trochlea groove recreation. A kinematically placed femoral component led to positioning considered unsafe in over 13% of cases. A functionally placed femoral component most closely restored trochlea depth in all three positions of flexion.

Functional Alignment Philosophy in Total Knee Arthroplasty-Rationale and Technique for the Valgus Morphotype Using an Image Based Robotic Platform and Individualized Planning

Functional alignment (FA) is a novel philosophy to deliver a total knee arthroplasty (TKA) that respects individual bony and soft tissue phenotypes within defined limitations. The purpose of this paper is to describe the rationale and technique of FA in the valgus morphotype with the use of an image-based robotic-platform. For the valgus phenotype the principles are personalized pre-operative planning, reconstitution of native coronal alignment without residual varus or valgus of more than 3°, restoration of dynamic sagittal alignment within 5° of neutral, implant sizing to match anatomy, and achievement of defined soft tissue laxity in extension and flexion through implant manipulation within the defined boundaries. An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable assessment of soft tissue laxity is performed in extension and flexion. Implant positioning is then manipulated in all three planes if necessary to achieve target gap measurements and a final limb position within a defined coronal and sagittal range. FA is a novel TKA technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that respects variations in individual anatomy and soft tissues within defined limits.

More passive internal tibial rotation with posterior cruciate ligament retention than with excision in a medial pivot TKA implanted with unrestricted caliper verified kinematic alignment

PURPOSE

Excision of the posterior cruciate ligament (PCL) is recommended when implanting a medial pivot (MP) total knee arthroplasty (TKA) to reduce the risk of limiting flexion by over-tensioning the flexion space. The present study determined whether PCL retention (1) limits internal tibial rotation and (2) causes anterior lift-off of the insert in 90° flexion after implantation of an MP design with unrestricted caliper verified kinematic alignment (KA).

METHODS

Four surgeons implanted an MP TKA design with medial ball-in-socket and lateral flat tibial insert in ten fresh-frozen cadaveric knees. Before and after PCL excision, trial inserts with medial goniometric markings measured the angular I-E tibial orientation relative to the trial femoral component's medial condyle in extension and at 90° flexion, and the surgeon recorded the occurrence of anterior lift-off of the insert at 90° flexion.

RESULTS

PCL retention resulted in greater internal tibial rotation than PCL excision, with mean values of 15° vs 7° degrees from maximum extension to 90° flexion, respectively (p < 0.0007). At 90° flexion, no TKAs with PCL retention and one TKA with PCL excision had anterior lift-off of the insert (N.S.).

CONCLUSIONS

This preliminary study of ten cadaveric knees showed that PCL retention restored more passive internal tibial rotation than PCL excision with a negligible risk of anterior lift-off. However, in vivo analysis from multiple authors with a larger sample size is required to recommend PCL retention with an MP TKA design implanted with unrestricted caliper verified KA.

Surgical epicondylar axis is not orthogonal to the femoral mechanical knee axis in valgus knees with primary osteoarthritis: Three-dimensional analysis according to knee coronal alignment in 112 patients

BACKGROUND

During total knee arthroplasty (TKA), most surgeons align the femoral component along the surgical epicondylar axis (SEA) considering it as orthogonal to the femoral mechanical axis. However, it is still unclear how SEA coronal alignment varies according to the native coronal knee alignment. The main goal of this study was to analyze the SEA orientation according to the native coronal knee morphotype.

METHODS

A total of 112 patients underwent a three-dimensional (3D) -planning-based TKA. The SEA was then determined by locating the epicondyles on 3D models. The 3D femoral and tibial mechanical axes were marked and the femoral (FMA) and tibial (TMA) mechanical angles were measured. The native HKA angle was measured as FMA + TMA. The SEA orientation angles were measured in the coronal (SEA-α) and axial (SEA-β) plane. SEA orientation was compared between the valgus, neutral, and varus knees.

RESULTS

The mean SEA-α angle was 90.2 ± 3° and the mean axial SEA-β angle was 92.2 ± 1.3°. The SEA-α angle was significantly higher in the valgus group compared with the neutral group (92.3 ± 2.9°, 90 ± 2.9°, P = 0.0009) whereas there was no significant difference in the SEA-α angle between the varus and the neutral group (89.7 ± 2.3°, 90 ± 2.9°, P = 0.32).

CONCLUSIONS

In contrast to the neutral and varus knees, the SEA was not orthogonal to the femoral mechanical axis in patients undergoing TKA for primary osteoarthritis. Our results suggest adapting the coronal alignment of the femoral component during TKA, while maintaining an average 2° valgus in valgus knees. By contrast, with varus and neutral knees, our data support the use of a mechanical alignment.

The Trochlear Groove of a Femoral Component Designed for Kinematic Alignment Is Lateral to the Quadriceps Line of Force and Better Laterally Covers the Anterior Femoral Resection Than a Mechanical Alignment Design

Background: A concern about kinematically aligned (KA) total knee arthroplasty (TKA) is that it relies on femoral components designed for mechanical alignment (MAd-FC) that could affect patellar tracking, in part, because of a trochlear groove orientation that is typically 6° from vertical. KA sets the femoral component coincident to the patient’s pre-arthritic distal and posterior femoral joint lines and restores the Q-angle, which varies widely. Relative to KA and the native knee, aligning the femoral component with MA changes most distal joint lines and Q-angles, and rotates the posterior joint line externally laterally covering the anterior femoral resection. Whether switching from a MAd- to a KAd-FC with a wider trochlear groove orientation of 20.5° from vertical results in radiographic measures known to promote patellar tracking is unknown. The primary aim was to determine whether a KAd-FC sets the trochlear groove lateral to the quadriceps line of force (QLF), better laterally covers the anterior femoral resection, and reduces lateral patella tilt relative to a MAd-FC. The secondary objective was to determine at six weeks whether the KAd-FC resulted in a higher complication rate, less knee extension and flexion, and lower clinical outcomes. Methods: Between April 2019 and July 2022, two surgeons performed sequential bilateral unrestricted caliper-verified KA TKA with manual instruments on thirty-six patients with a KAd- and MAd-FC in opposite knees. An observer measured the angle between a line best-fit to the deepest valley of the trochlea and a line representing the QLF that indicated the patient’s Q-angle. When the trochlear groove was lateral or medial relative to the QLF, the angle is denoted + or −, and the femoral component included or excluded the patient’s Q-angle, respectively. Software measured the lateral undercoverage of the anterior femoral resection on a Computed Tomography (CT) scan, and the patella tilt angle (PTA) on a skyline radiograph. Complications, knee extension and flexion measurements, Oxford Knee Score, KOOS Jr, and Forgotten Joint Score were recorded pre- and post-operatively (at 6 weeks). A paired Student’s T-test determined the difference between the KA TKAs with a KAd-FC and MAd-FC with a significance set at p < 0.05. Results: The final analysis included thirty-five patients. The 20.5° trochlear groove of the KAd-FC was lateral to the QLF in 100% (15 ± 3°) of TKAs, which was greater than the 69% (1 ± 3°) lateral to the QLF with the 6° trochlear groove of the MAd-FC (p < 0.001). The KAd-FC’s 2 ± 1.9 mm lateral undercoverage of the anterior femoral resection was less than the 4.4 ± 1.5 mm for the MAd-FC (p < 0.001). The PTA, complication rate, knee extension and flexion, and clinical outcome measures did not differ between component designs. Conclusions: The KA TKA with a KAd-FC resulted in a trochlear groove lateral to the QLF that included the Q-angle in all patients, and negligible lateral undercoverage of the anterior femoral resection. These newly described radiographic parameters could be helpful when investigating femoral components designed for KA with the intent of promoting patellofemoral kinematics.

Six Commonly Used Postoperative Radiographic Alignment Parameters Do Not Predict Clinical Outcome Scores after Unrestricted Caliper-Verified Kinematically Aligned TKA

Background: Unrestricted caliper-verified kinematically aligned (KA) TKA restores patient’s prearthritic coronal and sagittal alignments, which have a wide range containing outliers that concern the surgeon practicing mechanical alignment (MA). Therefore, knowing which radiographic parameters are associated with dissatisfaction could help a surgeon decide whether to rely on them as criteria for revising an unhappy patient with a primary KA TKA using MA principles. Hence, we determined whether the femoral mechanical angle (FMA), hip–knee–ankle angle (HKAA), tibial mechanical angle (TMA), tibial slope angle (TSA), and the indicators of patellofemoral tracking, including patella tilt angle (PTA) and the lateral undercoverage of the trochlear resection (LUCTR), are associated with clinical outcome scores. Methods: Forty-three patients with a CT scan and skyline radiograph after a KA TKA with PCL retention and medial stabilized design were analyzed. Linear regression determined the strength of the association between the FMA, HKA angle, PTS, PTA, and LUCTR and the forgotten joint score (FJS), Oxford knee score (OKS), and KOOS Jr score obtained at a mean of 23 months. Results: There was no correlation between the FMA (range 2° varus to −10° valgus), HKAA (range 10° varus to −9° valgus), TMA (range 10° varus to −0° valgus), TSA (range 14° posterior to −4° anterior), PTA (range, −10° medial to 14° lateral), and the LUCTR resection (range 2 to 9 mm) and the FJS (median 83), the OKS (median 44), and the KOOS Jr (median 85) (r = 0.000 to 0.079). Conclusions: Surgeons should be cautious about using postoperative FMA, HKAA, TMA, TSA, PTA, and LUCTR values within the present study’s reported ranges to explain success and dissatisfaction after KA TKA.

A TKA Insert with A Lateral Flat Articular Surface Maximizes External and Internal Tibial Orientations without Anterior Lift-Off Relative to Low- and Ultracongruent Surfaces

Background: In total knee arthroplasty (TKA), inserts can have different levels of medial and lateral congruency determined by the acuteness of the upslopes of the anterior and posterior articular surfaces. The present study evaluated an insert with different levels of lateral congruency and a medial ball-in-socket congruency to test the hypothesis that a lateral flat (F) insert maximizes external tibial orientation at extension and internal orientation at 90° flexion and lowers the incidence of anterior lift-off relative to low-congruent (LC) and ultracongruent (UC) lateral inserts. Methods: Two surgeons treated 23 patients with unrestricted caliper-verified kinematic alignment (KA) and posterior cruciate ligament (PCL) retention. They randomly trialed inserts with a medial radial dial that functioned as a built-in goniometer by measuring the tibial orientation relative to a sagittal line on the femoral trial component. Anterior lift-off of the insert from the baseplate indicated PCL tightness. Results: The F insert’s mean of 9° of external tibial orientation was higher than that of the LC (5°, p < 0.0001) and UC inserts (2°, p < 0.0001). The −13° of internal tibial orientation at 90° flexion was higher than that of the LC (−9°, p < 0.0001) and UC inserts (−7°, p < 0.0001). The 0% incidence of anterior lift-off was less than that of the LC (26%) and UC inserts (57%) (p < 0.0001). Conclusions: Surgeons and implant manufacturers should know that adding congruency to the lateral articular surface limits external tibial orientation in extension and internal tibial orientation at 90° flexion and overtightens the PCL. These rotational limitations and flexion space tightness can adversely affect patellofemoral tracking and knee flexion.

A Surgeon That Switched to Unrestricted Kinematic Alignment with Manual Instruments Has a Short Learning Curve and Comparable Resection Accuracy and Outcomes to Those of an Experienced Surgeon

After starting an orthopedic practice, a surgeon with a fellowship in mechanically aligned (MA) TKA initiated this study to characterize their learning curve after they switched to unrestricted kinematic alignment (KA) TKA using manual instruments. Accordingly, the present study determined for the inexperienced (IE) surgeon the number of cases required to achieve consistent femoral resections and operating times, and whether the femoral resection accuracy, patient-reported outcome measures (PROMs), and component alignment were different from an experienced (E) surgeon. This prospective cohort study analyzed the IE surgeon’s first 30 TKAs, all performed with KA, and 30 consecutive KA TKAs performed by an E surgeon. The resection accuracy or deviation was the calipered thickness of the distal and posterior medial and lateral femoral resections minus the planned resection thickness, which was the thickness of the corresponding condyle of the femoral component, minus 2 mm for cartilage wear, and 1 mm for the kerf of the blade. Independent observers recorded the femoral resection thickness, operative times, PROMs, and alignment. For each femoral resection, the deviation between three groups of patients containing ten consecutive KA TKAs, was either insignificant (p = 0.695 to 1.000) or within the 0.5 mm resolution of the caliper, which indicated no learning curve. More than three groups were needed to determine the learning curve for the operative time; however, the IE surgeon’s procedure dropped to 77 min for the last 10 patients, which was 20 min longer than the E surgeon. The resection deviations of the IE and E surgeon were comparable, except for the posterolateral femoral resection, which the IE surgeon under-resected by a mean of −0.8 mm (p < 0.0001). At a mean follow-up of 9 and 17 months, the Forgotten Joint Score, Oxford Knee Score, KOOS, and the alignment of the components and limbs were not different between the IE and E surgeon (p ≥ 0.6994). A surgeon that switches to unrestricted KA with manual instruments can determine their learning curve by computing the deviation of the distal and posterior femoral resections from the planned resection. Based on the present study, an IE surgeon could have resection accuracy, post-operative patient outcomes, and component alignment comparable to an E surgeon.

Current concept of kinematic alignment total knee arthroplasty and its derivatives

The kinematic alignment (KA) approach to total knee arthroplasty (TKA) has recently increased in popularity. Accordingly, a number of derivatives have arisen and have caused confusion. Clarification is therefore needed for a better understanding of KA-TKA. Calipered (or true, pure) KA is performed by cutting the bone parallel to the articular surface, compensating for cartilage wear. In soft-tissue respecting KA, the tibial cutting surface is decided parallel to the femoral cutting surface (or trial component) with in-line traction. These approaches are categorized as unrestricted KA because there is no consideration of leg alignment or component orientation. Restricted KA is an approach where the periarthritic joint surface is replicated within a safe range, due to concerns about extreme alignments that have been considered ‘alignment outliers’ in the neutral mechanical alignment approach. More recently, functional alignment and inverse kinematic alignment have been advocated, where bone cuts are made following intraoperative planning, using intraoperative measurements acquired with computer assistance to fulfill good coordination of soft-tissue balance and alignment. The KA-TKA approach aims to restore the patients’ own harmony of three knee elements (morphology, soft-tissue balance, and alignment) and eventually the patients’ own kinematics. The respective approaches start from different points corresponding to one of the elements, yet each aim for the same goal, although the existing implants and techniques have not yet perfectly fulfilled that goal.

Traditional Chinese-Hong Kong version of Forgotten Joint Score-12 (FJS-12) for patients with osteoarthritis of the knee underwent joint replacement surgery: cross-cultural and sub-cultural adaptation, and validation

Background

A patient-reported outcome (PRO) tool which reflects the outcomes of patients underwent total knee arthroplasty (TKA) are important to be “ceiling effect free” which commonly used PRO tools face. Forgotten joint score-12 (FJS-12) has been proved to reduce or even free from ceiling effect. FJS-12 has been translated to different languages. The objectives of this study are to validate FJS-12 in Traditional Chinese-Hong Kong language and look for the goodness of FJS-12 still exist in this language adapted FJS-12 version.

Methods

FJS-12 was administered to 75 patients whose majority was obese underwent TKA between September 2019 and March 2020. Patients completed 3 sets of questionnaires (FJS-12, Oxford Knee Score (OKS), and Numeric Rating Scale (NRS)) twice, 2 weeks apart. Reliability, internal consistency, responsiveness, test–retest agreement and discriminant validity were evaluated.

Results

Reliability of FJS-12 showed moderate to excellent internal consistency (Cronbach’s α = 0.870). Test–retest reliability of FJS-12 was good (ICC = 0.769). Bland–Altman plot showed good test–retest agreement. Construct validity in terms of correlations between FJS-12 and OKS, and FJS-12 and NRS were moderate at baseline (Pearson’s coefficient r = 0.598) and good at follow-up (r = 0.879). Smallest detectable change (Responsiveness) was higher than MIC. Floor effect was none observed, and ceiling effect was low. Discriminant validity was found to have no significance. BMI (obesity) did not affect FJS-12 outcomes.

Conclusions

The Traditional Chinese-Hong Kong version of FJS-12 showed good test–retest reliability, validity, responsiveness, BMI non-specific, with no floor and low ceiling effects for patients who underwent TKA. Sub-culture differences in individual PRO tools should be considered in certain ethnicities and languages.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05156-5.

Validation and modification of the Coronal Plane Alignment of the Knee classification in the Asian population

AIMS

The Coronal Plane Alignment of the Knee (CPAK) classification is a simple and comprehensive system for predicting pre-arthritic knee alignment. However, when the CPAK classification is applied in the Asian population, which is characterized by more varus and wider distribution in lower limb alignment, modifications in the boundaries of arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) should be considered. The purposes of this study were as follows: first, to propose a modified CPAK classification based on the actual joint line obliquity (aJLO) and wider range of aHKA in the Asian population; second, to test this classification in a cohort of Asians with healthy knees; third, to propose individualized alignment targets for different CPAK types in kinematically aligned (KA) total knee arthroplasty (TKA).

METHODS

The CPAK classification was modified by changing the neutral boundaries of aHKA to 0° ± 3° and using aJLO as a new variable. Radiological analysis of 214 healthy knees in 214 Asian individuals was used to assess the distribution and mean value of alignment angles of each phenotype among different classifications based on the coronal plane. Individualized alignment targets were set according to the mean lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) of different knee types.

RESULTS

A very high concentration, 191 from 214 individuals (89.3%), were found in knee types with apex distal JLO when the CPAK classification was applied in the Asian population. By using aJLO as a new variable, the high distribution percentage in knee types with apex distal JLO decreased to 125 from 214 individuals (58.4%). The most common types in order were Type II (n = 70; 32.7%), Type V (n = 55; 25.7%), and Type I (n = 46; 21.5%) in the modified CPAK classification.

CONCLUSION

The modified CPAK classification corrected the uneven distribution when applying the CPAK classification in the Asian population. Setting individualized TKA alignment targets according to CPAK type may be a practical method to recreate optimal LDFA and MPTA in KA-TKA. Cite this article: Bone Jt Open 2022;3(3):211-217.

What is the "safe zone" for transition of coronal alignment from systematic to a more personalised one in total knee arthroplasty? A systematic review

PURPOSE

In total knee arthroplasty (TKA), implants are increasingly aligned based on emerging patient-specific alignment strategies, such as unrestricted kinematic alignment (KA), according to their constitutional limb alignment (phenotype alignment), which results in a large proportion of patients having a hip-knee angle (HKA) outside the safe range of ± 3° to 180° traditionally considered in the mechanical alignment strategy. The aim of this systematic review is to investigate whether alignment outside the safe zone of ± 3° is associated with a higher revision rate and worse clinical outcome than alignment within this range.

METHODS

A systematic literature search was conducted in PubMed, Embase, Cochrane and World of Science, with search terms including synonyms and plurals for "total knee arthroplasty", "alignment", "outlier", "malalignment", "implant survival" and "outcome". Five studies were identified with a total number of 927 patients and 952 implants. The Oxford Knee Score (OKS) and the WOMAC were used to evaluate the clinical outcome. The follow-up period was between 6 months and 10 years.

RESULTS

According to HKA 533 knees were aligned within ± 3°, 47 (8.8%) were varus outliers and 121 (22.7%) were valgus outliers. No significant differences in clinical outcomes were found between implants positioned within ± 3° and varus and valgus outliers. Likewise, no significant differences were found regarding revision rates and implant survival.

CONCLUSION

The universal use of the "safe zone" of ± 3° derived from the mechanical alignment strategy is hardly applicable to modern personalised alignment strategies in the light of current literature. However, given the conflicting evidence in the literature on the risks of higher revision rates and poorer clinical outcomes especially with greater tibial component deviation, the lack of data on the outcomes of more extreme alignments, and regarding the use of implants for KA TKA that are actually designed for mechanical alignment, there is an urgent need for research to define eventual evidence-based thresholds for new patient-specific alignment strategies, not only for HKA but also for FMA and TMA, also taking into account the preoperative phenotype and implant design. It is of utmost clinical relevance for the application of modern alignment strategies to know which native phenotypes may be reproduced with a TKA.

LEVEL OF EVIDENCE

IV.

Adjusting Insert Thickness and Tibial Slope Do Not Correct Internal Tibial Rotation Loss Caused by PCL Resection: In Vitro Study of a Medial Constraint TKA Implanted with Unrestricted Calipered Kinematic Alignment

Most medial stabilized (MS) total knee arthroplasty (TKA) implants recommend excision of the posterior cruciate ligament (PCL), which eliminates the ligament's tension effect on the tibia that drives tibial rotation and compromises passive internal tibial rotation in flexion. Whether increasing the insert thickness and reducing the posterior tibial slope corrects the loss of rotation without extension loss and undesirable anterior lift-off of the insert is unknown. In 10 fresh-frozen cadaveric knees, an MS design with a medial ball-in-socket (i.e., spherical joint) and lateral flat insert was implanted with unrestricted calipered kinematic alignment (KA) and PCL retention. Trial inserts with goniometric markings measured the internal-external orientation relative to the femoral component's medial condyle at maximum extension and 90 degrees of flexion. After PCL excision, these measurements were repeated with the same insert, a 1 mm thicker insert, and a 2- and 4-mm shim under the posterior tibial baseplate to reduce the tibial slope. Internal tibial rotation from maximum extension and 90 degrees of flexion was 15 degrees with PCL retention and 7 degrees with PCL excision (p < 0.000). With a 1 mm thicker insert, internal rotation was 8 degrees (p < 0.000), and four TKAs lost extension. With a 2 mm shim, internal rotation was 9 degrees (p = 0.001) and two TKAs lost extension. With a 4 mm shim, internal rotation was 10 degrees (p = 0.002) and five TKAs lost extension and three had anterior lift-off. The methods of inserting a 1 mm thicker insert and reducing the posterior slope did not correct the loss of internal tibial rotation after PCL excision and caused extension loss and anterior lift-off in several knees. PCL retention should be considered when using unrestricted calipered KA and implanting a medial ball-in-socket and lateral flat insert TKA design, so the progression of internal tibial rotation and coupled reduction in Q-angle throughout flexion matches the native knee, optimizing the retinacular ligaments' tension and patellofemoral tracking.

Specific case consideration for implanting TKA with the Kinematic Alignment technique

The Kinematic Alignment (KA) technique for total knee arthroplasty (TKA) is an alternative surgical technique aiming to resurface knee articular surfaces.The restricted KA (rKA) technique for TKA applies boundaries to the KA technique in order to avoid reproducing extreme constitutional limb/knee anatomies.The vast majority of TKA cases are straightforward and can be performed with KA in a standard (unrestricted) fashion.There are some specific situations where performing KA TKA may be more challenging (complex KA TKA cases) and surgical technique adaptations should be included.To secure good clinical outcomes, complex KA TKA cases must be preoperatively recognized, and planned accordingly.The proposed classification system describes six specific issues that must be considered when aiming for a KA TKA implantation.Specific recommendations for each situation type should improve the reliability of the prosthetic implantation to the benefit of the patient.The proposed classification system could contribute to the adoption of a common language within our orthopaedic community that would ease inter-surgeon communication and could benefit the teaching of the KA technique. This proposed classification system is not exhaustive and will certainly be improved over time. Cite this article: EFORT Open Rev 2021;6:881-891. DOI: 10.1302/2058-5241.6.210042.

Restoring the Patient's Pre-Arthritic Posterior Slope Is the Correct Target for Maximizing Internal Tibial Rotation When Implanting a PCL Retaining TKA with Calipered Kinematic Alignment

INTRODUCTION

The calipered kinematically-aligned (KA) total knee arthroplasty (TKA) strives to restore the patient's individual pre-arthritic (i.e., native) posterior tibial slope when retaining the posterior cruciate ligament (PCL). Deviations from the patient's individual pre-arthritic posterior slope tighten and slacken the PCL in flexion that drives tibial rotation, and such a change might compromise passive internal tibial rotation and coupled patellofemoral kinematics.

METHODS

Twenty-one patients were treated with a calipered KA TKA and a PCL retaining implant with a medial ball-in-socket and a lateral flat articular insert conformity that mimics the native (i.e., healthy) knee. The slope of the tibial resection was set parallel to the medial joint line by adjusting the plane of an angel wing inserted in the tibial guide. Three trial inserts that matched and deviated 2°> and 2°< from the patient's pre-arthritic slope were 3D printed with goniometric markings. The goniometer measured the orientation of the tibia (i.e., trial insert) relative to the femoral component.

RESULTS

There was no difference between the radiographic preoperative and postoperative tibial slope (0.7 ± 3.2°, NS). From extension to 90° flexion, the mean passive internal tibial rotation with the pre-arthritic slope insert of 19° was greater than the 15° for the 2°> slope (p < 0.000), and 15° for the 2°< slope (p < 0.000).

DISCUSSION

When performing a calipered KA TKA with PCL retention, the correct target for setting the tibial component is the patient's individual pre-arthritic slope within a tolerance of ±2°, as this target resulted in a 15-19° range of internal tibial rotation that is comparable to the 15-18° range reported for the native knee from extension to 90° flexion.

An insert with less than spherical medial conformity causes a loss of passive internal rotation after calipered kinematically aligned TKA

INTRODUCTION

In total knee arthroplasty (TKA), the level of conformity, a medial stabilized (MS) implant, needs to restore native (i.e., healthy) knee kinematics without over-tensioning the flexion space when the surgeon chooses to retain the posterior cruciate ligament (PCL) is unknown. Whether an insert with a medial ball-in-socket conformity and lateral flat surface like the native knee or a less than spherical medial conformity restores higher and closer to native internal tibial rotation without anterior lift-off, an over-tension indicator, when implanted with calipered kinematic alignment (KA), is unknown.

METHODS AND MATERIALS

Two surgeons treated 21 patients with calipered KA and a PCL retaining MS implant. Validated verification checks that restore native tibial compartment forces in passive flexion without release of healthy ligaments were used to select the optimal insert thickness. A goniometer etched onto trial inserts with the ball-in-socket and the less than spherical medial conformity measured the tibial rotation relative to the femoral component at extension and 90° and 120° flexion. The surgeon recorded the incidence of anterior lift-off of the insert.

RESULTS

The insert with the medial ball-in-socket and lateral flat surface restored more internal tibial rotation than the one with less than spherical medial conformity, with mean values of 19° vs. 17° from extension to 90° flexion (p < 0.01), and 23° vs. 20°-120° flexion (p < 0.002), respectively. There was no anterior lift-off of the insert at 90° and 120° flexion.

CONCLUSION

An MS insert with a medial ball-in-socket and lateral flat surface that matches the native knee's spherical conformity restores native tibial internal rotation when implanted with calipered KA and PCL retention without over-tensioning the flexion space.