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Danaei B, McPhee J. Optimal Implant Positioning Following Total Knee Arthroplasty Using Predictive Dynamic Simulation. J Biomech Eng 2024; 146:111003. [PMID: 38959084 DOI: 10.1115/1.4065879] [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: 11/11/2023] [Accepted: 07/01/2024] [Indexed: 07/05/2024]
Abstract
In this paper, a novel method is proposed for the determination of the optimal subject-specific placement of knee implants based on predictive dynamic simulations of human movement following total knee arthroplasty (TKA). Two knee implant models are introduced. The first model is a comprehensive 12-degree-of-freedom (DoF) representation that incorporates volumetric contact between femoral and tibial implants, as well as patellofemoral contact. The second model employs a single-degree-of-freedom equivalent kinematic (SEK) approach for the knee joint. A cosimulation framework is proposed to leverage both knee models in our simulations. The knee model is calibrated and validated using patient-specific data, including knee kinematics and ground reaction forces. Additionally, quantitative indices are introduced to evaluate the optimality of implant positioning based on three criteria: balancing medial and lateral load distributions, ligament balancing, and varus/valgus alignment. The knee implant placement is optimized by minimizing the deviation of the indices from their user-defined desired values during predicted sit-to-stand motion. The method presented in this paper has the potential to enhance the results of knee arthroplasty and serve as a valuable instrument for surgeons when planning and performing this procedure.
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Affiliation(s)
- Behzad Danaei
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - John McPhee
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON N2L 3G1, Canada
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Chen M, Yang D, Shao H, Rui S, Cao Y, Zhou Y. Using sequential bone cutting to titrate soft tissue balance in total knee arthroplasty effectively minimizes soft tissue release. BMC Musculoskelet Disord 2023; 24:866. [PMID: 37936113 PMCID: PMC10631050 DOI: 10.1186/s12891-023-07005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 10/31/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Achieving soft tissue balance while maintaining limb alignment within acceptable boundaries is crucial for successful total knee arthroplasty (TKA). We proposed a sequential bone cutting (SBC) technique to titrate the soft tissue balance in robot-assisted TKA to achieve the desired balance with minimum soft tissue release. METHODS In total, 106 robot-assisted TKAs using the SBC technique were included. The preoperative hip-knee-ankle angle (HKA) was < 10° in 76 and ≥ 10° in 30 knees. The gaps were initially balanced with the help of the pre-resection balancing provided by the robotic system. Soft tissue balance and alignment were quantitatively measured after the initial bone cutting and final bone cutting. Additional adjustments (bone recuts and soft tissue releases) required to address soft tissue imbalance after initial bone cutting were recorded. The frequencies of soft tissue releases, soft tissue balance, and resultant alignment ≤ 3° were compared between non-severe (HKA < 10°) and severe deformity (HKA ≥ 10°) groups. RESULTS Soft tissue balance was achieved in 45 knees (42.5%) after initial bone cutting and in 93 knees (87.7%) after final balancing. The postoperative alignment was within 3° from neutral in 87 knees (82.1%) and 3-5° in 17 knees (16.0%). For unbalanced knees (n = 61) after initial bone cutting, soft tissue release was avoided by SBC in 37 knees (60.7%) and was deemed necessary in 24 knees (39.3%). Soft tissue release was more likely to be avoided in the non-severe deformity cohort (86.8% [33 of 38]) than in the severe deformity cohort (17.4% [4 of 23]; p < 0.001). The non-severe deformity cohort showed a significantly higher rate of resultant alignment ≤ 3° from neutral than the severe deformity cohort (90.8% vs. 60.0%; p < 0.001). CONCLUSION Pre-resection balancing is inappropriate to ensure soft tissue balance. The SBC technique is effective in minimizing soft tissue release while maintaining overall alignment within acceptable boundaries.
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Affiliation(s)
- Mingxue Chen
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Dejin Yang
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Hongyi Shao
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Shouwei Rui
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yuefeng Cao
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yixin Zhou
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
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Tu KC, Shih HT, Tang SC, Lee CH, Liao WJ, Wang SP. The Disproportionate Increase of the Intraoperative Flexion and Extension Gap Space after Posterior Cruciate Ligament Resection in Total Knee Arthroplasty. J Clin Med 2021; 10:jcm10184228. [PMID: 34575339 PMCID: PMC8472620 DOI: 10.3390/jcm10184228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose: Maintaining gap balance is critical for total knee arthroplasty (TKA). This study aimed to elucidate if the extension–flexion gaps would be changed with posterior cruciate ligament (PCL) intact (PI) and PCL resection (PR) during TKA. The flexion gaps were measured using two methods, open-(Fo) and closed-chain position (Fc), based on the definition of kinetic chain position, respectively. Methods: This retrospective study enrolled a total of 33 patients who underwent posterior-stabilized (PS) TKA for symptomatic advanced osteoarthritis of knees. After bone cuts were completed, the extension–flexion gaps before and after PCL resection during TKA were measured using a calibrated tensioning device set at a 100 Nm distraction force. To further differentiate the effect of thigh weight on the 90° flexion gap, two varied methods of examination, either in closed chain (Fc) or open chain (Fo) were performed. Results: The increases in the 90° knee flexion gap after PCL resection were measured by both methods, i.e., ΔFc (PR-Fc—PI-Fc): 2.04 ± 2.06 mm, p < 0.001; and mean ΔFo (PR-Fo—PI-Fo): 1.64 ± 1.36 mm, p < 0.001. However, there were no differences between ΔFc and ΔFo before and after PCL resection. A greater amount of flexion gap was identified in open chain than in closed chain after PCL resection, and the PR-Fo and PR-Fc were 14.36 ± 3.13 and 11.40 ± 3.47 (p < 0.001), respectively. Conclusions: The resection of PCL during TKA distinctly increased the flexion gap, but not the extension gap. This disproportionate increase of the gap will cause a gap balance mismatch. The tensioning maneuver in open-chain was more effective to detect the gap differences than in closed-chain before and after PCL resection during TKA.
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Affiliation(s)
- Kao-Chang Tu
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (K.-C.T.); (H.-T.S.); (S.-C.T.); (C.-H.L.); (W.-J.L.)
| | - Han-Ting Shih
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (K.-C.T.); (H.-T.S.); (S.-C.T.); (C.-H.L.); (W.-J.L.)
| | - Shih-Chieh Tang
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (K.-C.T.); (H.-T.S.); (S.-C.T.); (C.-H.L.); (W.-J.L.)
| | - Cheng-Hung Lee
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (K.-C.T.); (H.-T.S.); (S.-C.T.); (C.-H.L.); (W.-J.L.)
- Department of Food Science and Technology, Hungkuang University, Taichung 433304, Taiwan
- College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Wei-Jen Liao
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (K.-C.T.); (H.-T.S.); (S.-C.T.); (C.-H.L.); (W.-J.L.)
| | - Shun-Ping Wang
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (K.-C.T.); (H.-T.S.); (S.-C.T.); (C.-H.L.); (W.-J.L.)
- College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Sports Recreation and Health Management Continuing Studies-Bachelor’s Degree Completion Program, Tunghai University, Taichung 40704, Taiwan
- Correspondence: ; Tel.: +886-4-2359-2525 (ext. 5101); Fax: +886-4-2359-5046
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Seito N, Suzuki K, Mikami S, Uchida J, Hara N. The medial gap is a reliable indicator for intraoperative soft tissue balancing in posterior-stabilized total knee arthroplasty. Knee 2021; 29:68-77. [PMID: 33578283 DOI: 10.1016/j.knee.2021.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/06/2020] [Accepted: 01/08/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Appropriate soft tissue balance and accurate alignment are important for successful total knee arthroplasty (TKA). However, the optimal technique for establishing and measuring soft tissue balancing remains unclear. The aim of this study was to analyze the intraoperative medial and lateral gap pattern using digital knee balancer in posterior-stabilized (PS) TKA. METHODS This study involved 55 patients with medial osteoarthritis who underwent a primary TKA using an image-free navigation system. The extension gap and the flexion gap at 90° knee flexion were assessed using an offset seesaw-type digital balancer. Continuous joint distraction force from 10 lb to 60 lb was applied. Medial gap, lateral gap, and varus angle were measured. RESULTS The medial bone gap difference between extension and flexion was constant regardless of the distraction force from 20 lb to 60 lb. The lateral bone gap was significantly greater than the medial bone gap in extension and flexion from 30 lb to 60 lb (P < 0.05). The varus angle changed depending on the distraction force, especially in flexion. The varus angle in flexion was significantly greater than that in extension from 40 lb to 60 lb (P < 0.05). CONCLUSIONS The medial bone gap is a reliable indicator unaffected by the distraction force during surgery and is useful for adjusting the medial gap in extension and flexion appropriately to ensure medial stability in PS-TKA. The digital knee balancer and navigation system support both precise gap assessment and surgery.
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Affiliation(s)
- Naoki Seito
- Hokkaido Orthopaedic Memorial Hospital, Hiragishi, Toyohira-ku, Sapporo, Japan
| | - Koji Suzuki
- Hokkaido Orthopaedic Memorial Hospital, Hiragishi, Toyohira-ku, Sapporo, Japan.
| | - Susumu Mikami
- Hokkaido Orthopaedic Memorial Hospital, Hiragishi, Toyohira-ku, Sapporo, Japan
| | - Jun Uchida
- Hokkaido Orthopaedic Memorial Hospital, Hiragishi, Toyohira-ku, Sapporo, Japan
| | - Noriyuki Hara
- Hokkaido Orthopaedic Memorial Hospital, Hiragishi, Toyohira-ku, Sapporo, Japan
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Abstract
Total knee arthroplasty (TKA) is a satisfactory procedure for end-stage knee joint pathology. However, there is a significant incidence of unsatisfied patients. In recent years conventional total knee arthroplasty surgical technique has been challenged and a modern trend to respect individual anatomy, alignment and soft tissue laxities has been developed. The indications, limits and outcomes of these modern techniques in selected patients are not well-defined. Modern technology (navigation, patient-specific instrumentation and robotics) has improved accuracy of the osteotomies but their effect on long-term outcomes is still unclear. A technique which respects individual anatomy, laxities and alignment in combination with an implant which is designed to incorporate contemporary knee kinematics, without the use of modern technology, is presented.
Cite this article: EFORT Open Rev 2020;5:663-671. DOI: 10.1302/2058-5241.5.190085
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Affiliation(s)
- Theofilos Karachalios
- School of Health Sciences, Faculty of Medicine, University of Thessalia, Greece.,Orthopaedic Department, University General Hospital of Larissa, Greece
| | - George A Komnos
- Orthopaedic Department, University General Hospital of Larissa, Greece
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Abstract
For multifactorial reasons an estimated 20% of patients remain unsatisfied after total knee arthroplasty (TKA). Appropriate tension of the soft tissue envelope encompassing the knee is important in total knee arthroplasty and soft tissue imbalance contributes to several of the foremost reasons for revision TKA, including instability, stiffness and aseptic loosening. There is debate in the literature surrounding the optimum way to achieve balancing of a total knee arthroplasty and there is also a lack of an accepted definition of what a balanced knee replacement is. It may be intuitive to use the native knee as a model for balancing; however, there are many difficulties with translating this into a successful prosthesis. One of the foundations of TKA, as described by Insall, was that although the native knee has more weight transmitted through the medial compartment this was to be avoided in a TKA as it would lead to uneven wear and early failure. There is a focus on achieving symmetrical tension and pressure and subsequent ‘balance’ in TKA, but the evidence from cadaveric studies is that the native knee is not symmetrically balanced. As we are currently trying to design an implant that is not based on its anatomical counterpart, is it possible to create a truly balanced prosthesis or to even to define what that balance is? The authors have reviewed the current evidence surrounding TKA balancing and its relationship with the native knee.
Cite this article: EFORT Open Rev 2018;3:614-619. DOI: 10.1302/2058-5241.3.180008.
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Affiliation(s)
- Lucy C Walker
- Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Nick D Clement
- Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Kanishka M Ghosh
- Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - David J Deehan
- Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
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Willing R, Walker PS. Measuring the sensitivity of total knee replacement kinematics and laxity to soft tissue imbalances. J Biomech 2018; 77:62-68. [DOI: 10.1016/j.jbiomech.2018.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 06/05/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
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Burkhart TA, Herman BV, Perry K, Vandekerckhove PJ, Howard J, Lanting B. Standard versus physiologic bone preparation in total knee arthroplasty and the effect on joint space opening. Clin Biomech (Bristol, Avon) 2017; 49:155-161. [PMID: 28957738 DOI: 10.1016/j.clinbiomech.2017.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 08/22/2017] [Accepted: 09/14/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total knee arthroplasty is an effective treatment for osteoarthritis. Restoration of physiologic varus alignment may restore the native soft tissue tension and improve outcomes. METHODS Six paired fresh-frozen knee specimens were used to perform total knee arthroplastys. The left and right sides of were randomly assigned to have either a physiologic alignment cut or a standard of care neutral alignment bony cut prior to the implantation. Loads of 100 and 200N were applied at 0, 30, 60, and 90° of flexion and the magnitude of the medial and lateral compartment distraction was measured. The loads were applied with the knee specimen intact and post arthroplasty. FINDINGS The physiologic alignment had no difference between medial and lateral gaps at either load. With 100N of load the physiologic alignment had a greater gap at 90° than at full extension while the standard alignment had significantly more gap at 60° of flexion than full extension. The physiologic alignment had a significantly greater gap with the implant compared to the intact condition at both loads. The standard alignment had no significant difference in overall gap between the implant and intact condition with any load. INTERPRETATION Although performing a physiologic aligned TKA resulted in medial-lateral soft tissue balance, the flexion gap was found to have greater magnitude than the intact knee. Notably, a neutral aligned TKA was found to be balanced, but also was found to recreate the intact knee flexion gaps. These results suggest that coronal plane stability can be achieved with physiologic alignment objectives, but the clinician needs to be aware of the potential to have greater laxity than the intact and neutral alignment surgical objectives.
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Affiliation(s)
- Timothy A Burkhart
- Lawson Health Research Institute, Western University, Ontario N6A 5W9, Canada.
| | - Benjamin V Herman
- London Health Sciences Centre, Department of Surgery, Western University, Ontario, Canada.
| | | | | | - James Howard
- London Health Sciences Centre, Department of Surgery, Western University, Ontario, Canada.
| | - Brent Lanting
- London Health Sciences Centre, Department of Surgery, Western University, Ontario, Canada.
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Heesterbeek PJC, Haffner N, Wymenga AB, Stifter J, Ritschl P. Patient-related factors influence stiffness of the soft tissue complex during intraoperative gap balancing in cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25:2760-2768. [PMID: 26174467 DOI: 10.1007/s00167-015-3694-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 07/01/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE How much force is needed to pre-tension the ligaments during total knee arthroplasty? The goal of this study was to determine this force for extension and flexion, and for both compartments, and to identify predicting patient-related factors. METHODS Eighty patients [55 females, mean age 71 (SD 9.7)] were recruited and had a navigated cruciate-retaining total knee arthroplasty. Distraction of the medial and lateral compartments of the extension and flexion gap (90°) with an instrumented bi-compartmental double-spring tensioner took place after finishing the bone cuts. Applied forces and resulting gap distances were recorded by the navigation system, resulting in a force-elongation curve. Lines were fitted with the intersection defined as the stiffness transition point. The slopes (N/mm) represented the stiffness of the ligamentous complex. Linear multiple regression analysis was performed to identify predicting factors. RESULTS The amount of force at the stiffness transition point was on average 52.3 (CI95 50.7-53.9), 54.5 (CI95 52.7-56.3), 48.3 (CI95 46.2-50.2), and 59.3 (CI95 57.0-61.6) N for the medial and lateral extension and flexion gap, respectively, and varied considerably between patients. The force at the stiffness transition point was significantly different between extension and flexion and both compartments (P < 0.05). Stiffness of the ligaments statistically significantly helped to predict the amount of force at the stiffness transition point, as well as body mass index, gender, and varus-valgus alignment. CONCLUSION The amount of force at the stiffness transition point varies between 48 and 59 N, depending on flexion/extension and compartment. Patient-related factors influence the stiffness transition point and can help predict the stiffness transition point. When forces higher than 60 N are used for gap distraction, the ligamentous sleeve of the knee might be over-tensioned. LEVEL OF EVIDENCE Prognostic study, Level I-high-quality prospective cohort study with >80 % follow-up, and all patients enrolled at same time point in disease.
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Affiliation(s)
| | - N Haffner
- Orthopedic hospital Gersthof, Vienna, Austria
| | - A B Wymenga
- Sint Maartenskliniek Orthopaedics, Nijmegen, The Netherlands
| | | | - P Ritschl
- Orthopedic hospital Gersthof, Vienna, Austria
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Burkhart TA, Perry KI, Dobbin E, Howard J, Lanting B. Effect of Soft Tissue Releases on Joint Space Opening in Total Knee Arthroplasty. J Arthroplasty 2016; 31:2912-2916. [PMID: 27350023 DOI: 10.1016/j.arth.2016.05.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 05/03/2016] [Accepted: 05/10/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine the gap achieved to the medial and lateral compartments following sectioning and release of the relevant soft tissues in preparation for a total knee arthroplasty. METHODS A custom-designed knee tensioner allowed the application of forces to the medial and lateral compartments of 12 cadaveric knee specimens. Loads of 100 N and 200 N were applied to each compartment, and the resulting displacement was measured in the following conditions: (1) All soft tissues intact, (2) an arthrotomy, (3) anterior cruciate ligament (ACL) sectioned, (4) posterior cruciate ligament (PCL) sectioned, and (5) release of the anterior aspect of the deep medial collateral ligament (MCL) fibers. Tensions were applied for all conditions from 90° to 0° of knee flexion in 30° increments. RESULTS No differences were found in medial or lateral displacement after the arthrotomy or releasing the ACL or PCL at either 100 N or 200 N. At the 100 N load application, there was a significant increase in gap width when the anterior portion of the deep MCL was released (7.49 mm) compared to the intact (5.28 mm) and arthrotomy (5.75 mm) conditions. With respect to the 200 N load application, there were statistically significant differences detected between the deep MCL fiber release (11.09 mm) and intact conditions (8.05 mm) and release of the deep MCL and arthrotomy conditions (8.77 mm). CONCLUSION The medial parapetellar arthrotomy, ACL and PCL sectioning did not result in medial or lateral displacement changes. The release of the anterior fibers of the deep MCL as part of the surgical exposure increased the medial gap magnitude.
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Affiliation(s)
- Timothy A Burkhart
- Department of Surgery, Lawson Health Research Institute, London, Ontario, Canada; Department of Engineering, Western University, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Kevin I Perry
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Emily Dobbin
- Department of Kinesiology, Western University, London, Ontario, Canada
| | - James Howard
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - Brent Lanting
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
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Kwak DS, In Y, Kim TK, Cho HS, Koh IJ. The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24:188-94. [PMID: 25288338 DOI: 10.1007/s00167-014-3362-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 09/26/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite the documented clinical efficacy of the pie-crusting technique for medial collateral ligament (MCL) release in varus total knee arthroplasty, its quantitative effects on medial gaps and safety remain unclear. This study was undertaken to determine the efficacy (quantitative effect and consistency of the number of punctures) and the safety (frequency of early over-release) of the pie-crusting technique for MCL release. METHODS From ten pairs of cadaveric knees, one knee from each pair was randomly assigned to undergo pie crusting in extension (group E) or in flexion (group F). Pie crusting was performed in the superficial MCL using a blade until over-release occurred. After every puncture, the incremental medial gap increase was recorded, and the number of punctures required for 2- or 4-mm gap increases was assessed. RESULTS In group E, the extension gap increased from 0.8 to 5.0 mm and the flexion gap increased from 0.8 to 3.0 mm. In group F, the extension gap increased from 1.0 to 3.0 mm and the flexion gap increased from 2.6 to 6.0 mm. However, the gap increments were inconsistent with those that followed the preceding blade punctures, and the number of punctures required to increase the gaps by 2 or 4 mm was variable. The number of punctures leading to over-release in group E and group F was 6 ± 1 and 3 ± 1 punctures, respectively. Overall, 70% of over-release occurred earlier than the average number of punctures leading to over-release. CONCLUSIONS Pie crusting led to unpredictable gap increments and to frequent early over-release. Surgeons should decide carefully before using the pie-crusting technique for MCL release and should be cautious of performing throughout the procedure, especially when performing in a flexed knee. LEVEL OF EVIDENCE Therapeutic study, Level I.
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Affiliation(s)
- Dai-Soon Kwak
- Catholic Institute for Applied Anatomy, The Catholic University of Korea College of Medicine, Seoul, 137-701, Korea
| | - Yong In
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
- Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, 137-701, Korea
| | - Tae Kyun Kim
- Joint Reconstruction Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 463-707, Korea
| | - Han Suk Cho
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
- Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, 137-701, Korea
| | - In Jun Koh
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea.
- Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, 137-701, Korea.
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Nakamura S, Ito H, Yoshitomi H, Kuriyama S, Komistek RD, Matsuda S. Analysis of the Flexion Gap on In Vivo Knee Kinematics Using Fluoroscopy. J Arthroplasty 2015; 30:1237-42. [PMID: 25680453 DOI: 10.1016/j.arth.2015.01.046] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 01/16/2015] [Accepted: 01/29/2015] [Indexed: 02/01/2023] Open
Abstract
There is a paucity of information on the relationships between postoperative knee laxity and in vivo knee kinematics. The correlations were analyzed in 22 knees with axial radiographs and fluoroscopy based 3D model fitting approach after a tri-condylar total knee arthroplasty. During deep knee bend activities, the medial flexion gap had significant correlations with the medial contact point (r=0.529, P=0.011) and axial rotation at full extension. During kneeling activities, a greater medial flexion gap caused larger anterior translation at complete contact (r=0.568, P=0.011). Meanwhile, the lateral flexion gap had less effect. In conclusion, laxity of the medial collateral ligament should be avoided because the magnitude of medial flexion stability was crucial for postoperative knee kinematics.
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Affiliation(s)
- Shinichiro Nakamura
- Department of Orthopedic Surgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan; Center for Musculoskeletal Research, University of Tennessee, Knoxville, TN
| | - Hiromu Ito
- Department of Orthopedic Surgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Hiroyuki Yoshitomi
- Department of Orthopedic Surgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Shinichi Kuriyama
- Department of Orthopedic Surgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Richard D Komistek
- Center for Musculoskeletal Research, University of Tennessee, Knoxville, TN
| | - Shuichi Matsuda
- Department of Orthopedic Surgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
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Abstract
BACKGROUND Methods to improve gap balancing in total knee arthroplasty (TKA) include the development of calibrated distractors and various devices to determine the distances of the gaps. However, few studies have validated the accuracy or precision of computer navigation to determine these measurements, especially gaps created after bone cuts have been made; doing so would be important, because optimal surgical technique relies on appropriate gap spacing. QUESTIONS/PURPOSES We investigated the ability of a new image-free computer navigation surface registration protocol to measure gap distances in TKA. METHODS Eight embalmed cadaveric specimens of the lower extremity were used. A surface registration software protocol defined the most distal and posterior surface points of the femoral condyles and the navigation system measured the distance of the most distal femoral condyle point to the surface of the tibia after tibial resection. The tibial resection was perpendicular to the mechanical axis and was cut with a 7° posterior slope. The navigation system measured gaps spaced by modular spacing blocks at 5° intervals from full extension to 120° of flexion. Repeatability assessed repeated measures by one surgeon. Reproducibility was assessed by performing the same measurements after complete reregistration of the computer protocol to the cadaver bones. RESULTS The gaps measured by the computer were statistically the same as those assessed with the use of blocks with a maximum measurement error of 1 mm. Reregistration did introduce error into the measurement. The gaps changed with position of knee flexion, and there was gradual and significant stretching of the gaps with repeated measurements. CONCLUSIONS Preliminary testing shows that computer navigation can reproduce static measurements reliably and with equal accuracy as spacer blocks. We have not demonstrated that this could be applied in a dynamic setting. CLINICAL RELEVANCE This computer navigation system has sufficient precision to warrant investigation in the clinical setting for measuring gaps created during the surgical procedure.
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Koh IJ, Kwak DS, Kim TK, Park IJ, In Y. How effective is multiple needle puncturing for medial soft tissue balancing during total knee arthroplasty? A cadaveric study. J Arthroplasty 2014; 29:2478-83. [PMID: 24360488 DOI: 10.1016/j.arth.2013.11.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/05/2013] [Accepted: 11/03/2013] [Indexed: 02/01/2023] Open
Abstract
We investigated the quantitative effect and risk factors for over-release during multiple needle puncturing (MNP) for medial gap balancing in varus total knee arthroplasty (TKA). Of the ten pairs of cadaveric knees, one knee from each pair was randomly assigned to undergo MNP in extension (E group), while the other knee underwent MNP in flexion (F group). The increased extension and 90° flexion gaps after every five needle punctures were measured until over-release occurred. The extension gap (< 4mm) and the 90° flexion gap (< 6mm) gradually increased in both groups. The 90° flexion gaps increased more selectively than did the extension gaps. MNP in the flexed knee, a narrow MCL, and severe osteoarthritis were associated with a smaller number of MNPs required to over-release.
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Affiliation(s)
- In Jun Koh
- Department of Orthopaedic Surgery, Uijeongbu St. Mary's Hospital, Uijeongbu-si, Gyeonggi-do, Korea; Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Tae Kyun Kim
- Joint Reconstruction Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - In Joo Park
- Department of Orthopaedic Surgery, Uijeongbu St. Mary's Hospital, Uijeongbu-si, Gyeonggi-do, Korea; Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong In
- Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea; Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Korea
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Lee JK, Chung KS, Kim BH, Choi CH. Flexion Gap Measured in 45 Degrees and 90 Degrees of Hip Flexion Positions during Total Knee Arthroplasty: Measurement by Navigation System. Knee Surg Relat Res 2014; 26:77-81. [PMID: 24944972 PMCID: PMC4061410 DOI: 10.5792/ksrr.2014.26.2.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 03/11/2014] [Accepted: 03/14/2014] [Indexed: 10/29/2022] Open
Abstract
PURPOSE To evaluate the influence of thigh weight in different hip flexion positions on the knee flexion gap in total knee arthroplasty (TKA). MATERIALS AND METHODS We evaluated 20 patients (25 knees) with osteoarthritis of the knee that underwent TKA using a navigation system from May 2010 to April 2011. After posterior cruciate ligament sacrificing, complete soft tissue balancing, and fixation of all components with cement, the flexion gaps were measured with the patello-femoral joint reduced. Medial and lateral flexion gaps were measured separately in both the 90°-90° and 45°-90° flexion positions of the hip-knee joints. RESULTS The medial and lateral flexion gaps in the 45°-90° flexion position of the hip-knee joints were 13.02±2.17 mm and 13.12±2.21 mm, respectively. The medial and lateral flexion gaps in the 90°-90° flexion position were 12.92±2.03 mm and 13.08±2.29 mm, respectively. The flexion gaps showed no significant (p>0.05) differences between the two different hip flexion positions. CONCLUSIONS Flexion gaps in TKA were not influenced by hip flexion positions (45° or 90° of flexion). Therefore, soft tissue balancing and polyethylene thickness should not be affected by hip flexion positions during TKA.
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Affiliation(s)
- Jin Kyu Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Kyu-Sung Chung
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Bo-Hyun Kim
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Choong Hyeok Choi
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
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Nowakowski AM, Kamphausen M, Pagenstert G, Valderrabano V, Müller-Gerbl M. Influence of tibial slope on extension and flexion gaps in total knee arthroplasty: increasing the tibial slope affects both gaps. INTERNATIONAL ORTHOPAEDICS 2014; 38:2071-7. [PMID: 24859924 DOI: 10.1007/s00264-014-2373-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 05/02/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Increasing the tibial slope is often performed if the flexion gap is narrower than the extension gap. The main hypothesis of this study is that increasing the tibial slope coincidentally enlarges the extension gap. METHODS Twenty formalin-fixed cadaveric knees were obtained for study. After CT in full extension and 90° flexion, the data of each specimen were entered into a standardized coordinate system and virtual bone cuts were performed with incrementally increasing the posterior slope. Gaps were measured at tibiofemoral contact points in 90°-flexion and full extension in the medial and lateral compartment. RESULTS Increasing the tibial slope did significantly widen both the extension and the flexion gaps (p < 0.001). In extension, the opening rates, i.e. the gap increase per degree of slope increase, were equal medially and laterally (0.5 mm ±0.1) medial vs 0.6 mm (±0.0) lateral), whereas in flexion the lateral gap did open significantly more than the medial one (0.6 mm ±0.1) medial vs 0.9 mm (±0.1) lateral (p < 0.001), resulting in a significantly greater flexion gap laterally. CONCLUSIONS Increasing the tibial slope beyond the pre-operative planning in order to widen a tight flexion gap intra-operatively is not recommended as doing so will increase the extension gap simultaneously and will make the medial and lateral flexion gaps unequal.
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17
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In vivo gap analysis in various knee flexion angles during navigation-assisted total knee arthroplasty. J Arthroplasty 2013; 28:1796-800. [PMID: 23721906 DOI: 10.1016/j.arth.2013.04.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 04/10/2013] [Accepted: 04/28/2013] [Indexed: 02/01/2023] Open
Abstract
Achieving rectangular flexion and extension gaps is important during gap balancing technique in total knee arthroplasty (TKA). However, assessment of gaps throughout the range of knee motion is obscure. One hundred knees operated by TKA using a navigation-assisted gap balancing technique were evaluated. Intraoperatively, after achieving rectangular flexion and extension gaps, mediolateral gaps in each flexion angle (0°, 45°, 90°, 120°) were recorded. Patients were divided into 4 groups; Group I: no gap difference (n = 64), Group II: lax in midflexion (n = 20), Group III: lax in deep flexion (n = 8) and Group IV: lax in both midflexion and deep flexion (n = 8). This study demonstrated that significant proportion (36%) of TKA cases had laxity in midflexion (45°) even when rectangular extension (0°)-flexion (90°) gap was achieved.
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Tsukada S, Hoshino A, Cho S, Ikeda H. Intraoperative soft tissue tension and postoperative range of motion in posterior stabilized total knee arthroplasty. Arch Orthop Trauma Surg 2013; 133:243-51. [PMID: 23117898 DOI: 10.1007/s00402-012-1646-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Intraoperative soft tissue tension can significantly impact the range of motion following total knee arthroplasty (TKA). However, the level of impact remains unclear. The purpose of this study was to investigate the relationship between intraoperative soft tissue tension and postoperative range of motion. METHODS This retrospective study included 504 patients operated with posterior stabilized TKA. During surgery, we adjusted the soft tissue tension from 80 to 160 N for both flexion and extension with the tensor/balancer device and torque driver. Patients were grouped into three categories based on intraoperative soft tissue tension and analyzed with the 1-year postoperative range of motion using one-way analysis of variance (ANOVA). In addition, Pearson's correlation coefficients were determined to assess the association between intraoperative soft tissue tension and postoperative range of motion. RESULTS The absolute tension value at 90° flexion did not affect the postoperative flexion angle (p = 0.61). The absolute tension value at 0° extension did not affect the postoperative extension angle (p = 0.91). Likewise, the difference of tension between flexion and extension did not affect the postoperative flexion angle (p = 0.86). All comparisons did not have the differences in sex, height, weight, body mass index, diagnosis and preoperative range of motion between three groups. No significant correlation was found in each comparison (r = 0.078, r = 0.031, r = -0.052, respectively). CONCLUSIONS We did not observe a correlation between intraoperative soft tissue tension adjusted from 80 to 160 N and 1-year postoperative range of motion in posterior stabilized TKA.
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Affiliation(s)
- Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Kawaguchi Kogyo General Hospital, 1-18-15 Aoki, Kawaguchi, Saitama, 332-0031, Japan.
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Kwak DS, Kong CG, Han SH, Kim DH, In Y. Development of a pneumatic tensioning device for gap measurement during total knee arthroplasty. Clin Orthop Surg 2012; 4:188-92. [PMID: 22949949 PMCID: PMC3425648 DOI: 10.4055/cios.2012.4.3.188] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 12/20/2011] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Despite the importance of soft tissue balancing during total knee arthroplasty (TKA), all estimating techniques are dependent on a surgeon's manual distraction force or subjective feeling based on experience. We developed a new device for dynamic gap balancing, which can offer constant load to the gap between the femur and tibia, using pneumatic pressure during range of motion. METHODS To determine the amount of distraction force for the new device, 3 experienced surgeons' manual distraction force was measured using a conventional spreader. A new device called the consistent load pneumatic tensor was developed on the basis of the biomechanical tests. Reliability testing for the new device was performed using 5 cadaveric knees by the same surgeons. Intraclass correlation coefficients (ICCs) were calculated. RESULTS The distraction force applied to the new pneumatic tensioning device was determined to be 150 N. The interobserver reliability was very good for the newly tested spreader device with ICCs between 0.828 and 0.881. CONCLUSIONS The new pneumatic tensioning device can enable us to properly evaluate the soft tissue balance throughout the range of motion during TKA with acceptable reproducibility.
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Affiliation(s)
- Dai-Soon Kwak
- Department of Anatomy, Catholic Institute for Applied Anatomy, The Catholic University of Korea School of Medicine, Seoul, Korea
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Nowakowski AM, Majewski M, Müller-Gerbl M, Valderrabano V. Measurement of knee joint gaps without bone resection: "physiologic" extension and flexion gaps in total knee arthroplasty are asymmetric and unequal and anterior and posterior cruciate ligament resections produce different gap changes. J Orthop Res 2012; 30:522-7. [PMID: 22416291 DOI: 10.1002/jor.21564] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
General agreement is that flexion and extension gaps should be equal and symmetrical in total knee arthroplasty (TKA) procedures. However, comparisons using a standard TKA approach to normal knee joints that have not undergone bone resection are currently unavailable. Since bony preparation can influence capsule and ligament tension, our purpose was to perform measurements without this influence. Ten normal cadaveric knees were assessed using a standard medial parapatellar TKA approach with patellar subluxation. Gap measurements were carried out twice each alternating 100 and 200 N per compartment using a prototypical force-determining ligament balancer without the need for bony resection. Initial measurements were performed in extension, followed by 908 of flexion. The ACL was then resected, and finally the PCL was resected, and measurements were carried out in an analogous fashion. In general, the lateral compartment could be stretched further than the medial compartment, and the corresponding flexion gap values were significantly larger. ACL resection predominantly increased extension gaps, while PCL resection increased flexion gaps. Distraction force of 100 N per compartment appeared adequate; increasing to 200 N did not improve the results.
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