Malposition of components and Femorotibial mechanical Axis changes on pressure distribution in Total knee arthroplasty

Prediction of knee biomechanics with different tibial component malrotations after total knee arthroplasty: conventional machine learning vs. deep learning

The precise alignment of tibiofemoral components in total knee arthroplasty is a crucial factor in enhancing the longevity and functionality of the knee. However, it is a substantial challenge to quickly predict the biomechanical response to malrotation of tibiofemoral components after total knee arthroplasty using musculoskeletal multibody dynamics models. The objective of the present study was to conduct a comparative analysis between a deep learning method and four conventional machine learning methods for predicting knee biomechanics with different tibial component malrotation during a walking gait after total knee arthroplasty. First, the knee contact forces and kinematics with different tibial component malrotation in the range of ±5° in the three directions of anterior/posterior slope, internal/external rotation, and varus/valgus rotation during a walking gait after total knee arthroplasty were calculated based on the developed musculoskeletal multibody dynamics model. Subsequently, deep learning and four conventional machine learning methods were developed using the above 343 sets of biomechanical data as the dataset. Finally, the results predicted by the deep learning method were compared to the results predicted by four conventional machine learning methods. The findings indicated that the deep learning method was more accurate than four conventional machine learning methods in predicting knee contact forces and kinematics with different tibial component malrotation during a walking gait after total knee arthroplasty. The deep learning method developed in this study enabled quickly determine the biomechanical response with different tibial component malrotation during a walking gait after total knee arthroplasty. The proposed method offered surgeons and surgical robots the ability to establish a calibration safety zone, which was essential for achieving precise alignment in both preoperative surgical planning and intraoperative robotic-assisted surgical navigation.

Aseptic survival of the 1.5-stage exchange arthroplasty for periprosthetic joint infection was acceptable when using an autoclaved femoral component and a new polyethylene insert

PURPOSE

To investigate the aseptic survival of 1.5-stage exchange arthroplasty for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA).

METHODS

Eighty-eight cases of 1.5-stage exchange arthroplasty for PJI without reinfection were retrospectively analysed. The autoclaved femoral component and new polyethylene insert (PE) were implanted using antibiotic mixed cement. The explanted tibial component was not reinserted. The Western Ontario and McMaster Universities Osteoarthritis Index and range of motion were clinically evaluated preoperatively and at the last follow-up (the last time for the implant in situ). Radiographically, hip-knee-ankle angle (HKA) and component positions were measured preoperatively, postoperatively (1 month after the 1.5-stage exchange arthroplasty), and at the last follow-up. The survival rate was analysed using the Kaplan-Meier method, in which failure was defined as reoperation due to aseptic failure. Mean period to failure and failure site were analysed. Factors affecting survival were investigated in terms of demographics and inappropriateness of the postoperative HKA (HKA > 0 ± 3°) and component positions (α angle > 95 ± 3°, β angle > 90 ± 3°, γ angle > 3 ± 3°, and δ angle > 87 ± 3°).

RESULTS

The spacer in-situ time was 3.7 years (0.2-6.4). The clinical results improved hip-knee-ankle significantly at the last follow-up. Radiographically, the average HKA was valgus 0.1° postoperatively. The average α, β, γ, and δ angles of the postoperative component positions were 95.9°, 90.4°, 3.8°, and 86.7°, respectively. The 1-, 2-, and 5-year postoperative survival rates were 90.9%, 86.4%, and 80.6%, respectively. The mean period to failure was 2.0 years (0.2-5.3). There were 18 cases of aseptic loosening (20.8%), occurring on both the femur and tibial sides in 1 knee, and only on the tibial side in 17 knees. Inappropriate coronal position of the PE (β angle > 90 ± 3°) was a significant factor affecting survival (odds ratio = 5.491; p = 0.011).

CONCLUSION

The aseptic survival of the 1.5-stage exchange arthroplasty was acceptable when using an autoclaved femoral component and new PE. The appropriate coronal position of the PE helps ensure favourable survival of 1.5-stage exchange arthroplasty.

LEVEL OF EVIDENCE

IV.

Mechanical alignment tolerance of a cruciate-retaining knee prosthesis under gait loading—A finite element analysis

Component alignment is one of the most crucial factors affecting total knee arthroplasty’s clinical outcome and survival. This study aimed to investigate how coronal, sagittal, and transverse malalignment affects the mechanical behavior of the tibial insert and to determine a suitable alignment tolerance on the coronal, sagittal, and transverse planes. A finite element model of a cruciate-retaining knee prosthesis was assembled with different joint alignments (−10°, −7°, −5°, −3°, 0°, 3°, 5°, 7°, 10°) to assess the effect of malalignment under gait loading. The results showed that varus or valgus, extension, internal rotation, and excessive external rotation malalignments increased the maximum Von Mises stress and contact pressure on the tibial insert. The mechanical alignment tolerance of the studied prosthesis on the coronal, sagittal, and transverse planes was 3° varus to 3° valgus, 0°–10° flexion, and 0°–5° external rotation, respectively. This study suggests that each prosthesis should include a tolerance range for the joint alignment angle on the three planes, which may be used during surgical planning.

Kinematic Alignment in Total Knee Arthroplasty Reduces Polyethylene Contact Pressure by Increasing the Contact Area, When Compared to Mechanical Alignment—A Finite Element Analysis

Unrestricted Kinematic alignment (KA) in total knee arthroplasty (TKA) replicates the joint line of each patient by adjusting the cuts based on the anatomy of the patient. Mechanical alignment (MA) aims to restore a neutral mechanical axis of the leg, irrespective of the joint line orientation. The purpose of the present study was to compare contact pressure and contact areas of the polyethylene (PE) bearing surface as well as von Mises stress of the PE-tibial tray interface for MA and KA in the same patient, using CT data and finite element analysis. Finite element models were created from lower leg CT scans of 10 patients with knee osteoarthritis with different phenotypes. Mechanical PE properties were experimentally determined by tensile tests on dumbbell specimens. For numerical simulation purposes an adjusted non-linear material model with the maximum load to failure of 30.5 MPa, was calibrated and utilized. Contact pressure points were the deepest parts of the polyethylene inlay. Contact pressures were either very similar or were increased for MA knees throughout the gait cycle. KA either increased or had a comparable contact area, compared to MA. KA and MA produced comparable von Mises stresses, although both alignments breached the failure point of 30.5 MPa in all 3 valgus knees. This might indicate a higher probability of failure at the inlay-tibial baseplate interface. By maintaining the joint line orientation, KA reduces or has comparable contact pressures on the PE bearing surface by increasing or maintaining the contact area throughout one gait cycle in a validated finite element analysis model in 10 different knee phenotypes. The von Mises stress on the PE-tibial component interface was comparable, except for the valgus knees, where the load to failure was achieved in both alignment strategies and slightly higher stresses were observed for KA. Further studies for different knee phenotypes are needed to better understand the pressure changes depending on the alignment strategy applied.