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Dahlmann S, Ziegeler K, Mau-Möller A, Mittelmeier W, Bergschmidt P. Patellar Tracking in Total Knee Arthroplasty-Influence on Clinical and Functional Outcome. Diagnostics (Basel) 2022; 12:diagnostics12051082. [PMID: 35626238 PMCID: PMC9139248 DOI: 10.3390/diagnostics12051082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/22/2022] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Anterior knee pain is a common problem after primary total knee arthroplasty (TKA). The aim of this study was to find parameters in patellar positioning which influence the clinical and functional outcome after TKA. Included were 59 patients who underwent TKA, of which three patients were treated bilaterally (n = 62 included knees). In a periodical follow-up of up to 5 years, each patient had to answer three questionnaires (HSS, WOMAC, SF-36) and underwent three radiographies of the knee (including merchant view) and a clinical examination, including Range Of Motion (ROM). All radiographs were evaluated by a single observer blinded to clinical data, who collected multiple parameters of sagittal and axial patellar alignment including newly developed methods for measuring patellar shift and tilt. Depending on the measurement results, three groups were built for each parameter and the influence on the outcome was determined. A lateral patellar tilt of more than 4° resulted in lower scores for both the HSS and WOMAC. The rarely investigated patellar facet angle showed a significantly inferior clinical and functional outcome in late follow-up of >24 months if lower than 142°, possibly due to progressive osteosclerotic changes of the patella caused by increased contact stress with corresponding patellar morphology. No significant difference was found for all other parameters. The newly developed method for measuring patellar shift has proven to be a valuable and easy instrument in the postoperative setting.
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Affiliation(s)
- Sebastian Dahlmann
- Department of Radiology, Charité Universitätsmedizin Berlin, Luisenstraße 7, 10117 Berlin, Germany;
- Correspondence:
| | - Katharina Ziegeler
- Department of Radiology, Charité Universitätsmedizin Berlin, Luisenstraße 7, 10117 Berlin, Germany;
| | - Anett Mau-Möller
- Orthopaedic Clinic and Outpatient Department, University Medicine Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (A.M.-M.); (W.M.); (P.B.)
| | - Wolfram Mittelmeier
- Orthopaedic Clinic and Outpatient Department, University Medicine Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (A.M.-M.); (W.M.); (P.B.)
| | - Philipp Bergschmidt
- Orthopaedic Clinic and Outpatient Department, University Medicine Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (A.M.-M.); (W.M.); (P.B.)
- Department for Orthopaedic Surgery, Trauma Surgery and Hand Surgery, Südstadt Hospital Rostock, Südring 81, 18059 Rostock, Germany
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Naveen NB, Deckard ER, Ziemba-Davis M, Hanson LF, Warth LC, Meneghini RM. Patellar tilt does not affect patient reported outcomes after modern total knee arthroplasty. Knee 2022; 34:167-177. [PMID: 34933237 DOI: 10.1016/j.knee.2021.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/19/2021] [Accepted: 11/25/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The focus of patella maltracking after total knee arthroplasty (TKA) has traditionally been on patella polyethylene damage and failure mechanisms rather than functional outcomes. The purpose of this study was to evaluate the effect of patellar tilt on patient reported outcomes (PROMS) after primary TKA performed with patellar resurfacing. METHODS A retrospective review using a single implant design was performed. Patella tilt was radiographically measured according to a standardized protocol. PROMS related to pain, function, and satisfaction were evaluated preoperatively and at minimum 1-year follow-up. RESULTS A total of 468 TKAs were included for analysis. Mean age and BMI were 64 years and 35 kg/m2; respectively while 63% of patients were female. The median follow-up period was 12.7 months. Overall, patellar tilt was corrected from a median of 5.0 degrees preoperatively to a median of 3.0 degrees postoperatively. Preoperative, postoperative, and the change in patellar tilt had no significant effects on PROMS at minimum 1-year follow-up (p ≥ 0.092). Satisfaction in knee function while getting out of bed was higher for patients with approximately the same patellar tilt before and after TKA compared to patients with an increase in lateral patellar tilt (95% vs 80%, p = 0.025). CONCLUSIONS The range of patellar tilt studied in this cohort had little to no effect on PROMS. However, suboptimal patellar tracking may potentiate edge loading of the polyethylene and contribute to implant damage in the long-term. These results are helpful to focus efforts on the tibiofemoral articulation as the predominant determinant of patient outcomes.
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Affiliation(s)
- Neal B Naveen
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mary Ziemba-Davis
- Indiana University Health Physicians, IU Health Hip & Knee Center, Fishers, IN, USA
| | - Logan F Hanson
- Otsego Memorial Hospital Orthopaedic and Rehab Center, Gaylor, MI, USA
| | - Lucian C Warth
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Health Physicians, IU Health Hip & Knee Center, Fishers, IN, USA
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Health Physicians, IU Health Hip & Knee Center, Fishers, IN, USA.
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Improving radiographic patello-femoral tracking in total knee arthroplasty with the use of a flexion spacer: a case-control study. Knee Surg Sports Traumatol Arthrosc 2021; 29:586-593. [PMID: 32279109 DOI: 10.1007/s00167-020-05991-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to compare the effectiveness of a flexion spacer in the clinical and radiological outcomes of patients who underwent total knee arthroplasty (TKA) and to compare these patients to a group of patients subjected to the same type of surgery but without the use of a flexion spacer. It was hypothesized that patients who underwent TKA using a flexion spacer would have better clinical and radiological outcomes than those without a flexion spacer in both short- and medium-term follow-ups. METHODS A consecutive series of patients undergoing TKA were included, yielding 20 patients in the study group. The control group was identified from the consultant database of the senior author, yielding 21 patients who underwent the same operation. All 41 patients received a Vanguard Knee System (Zimmer-Biomet, Warsaw, Indiana, USA). Cases were defined as those patients who had undergone TKA using a flexion spacer device for gap balancing; controls were defined as patients who had undergone TKA without the support of a flexion spacer device. Patients were clinically and radiographically evaluated at two consecutive follow-ups: T1-13.1 ± 1.3 months and T2-108 ± 6 months. Clinical evaluation was performed using the Knee Society Scoring System and the Western Ontario, McMaster Universities Osteoarthritis Index score. Radiographic evaluation included the femoral angle (α), the tibial angle (β), the sagittal femoral (γ) angle and the tibial slope (δ). Furthermore, the lateral patellofemoral angle (LPFA) and the Caton-Deschamps index were evaluated. RESULTS No statistically significant clinical differences were found between the two groups at T1 and T2; moreover, the clinical outcomes of the two groups were stable between the two follow-ups, with no significant improvement or worsening. Radiographic evaluation showed no difference in the two groups between T1 and T2; the only significant radiographic difference between the two groups concerned the LPFA (both at 30° and 60°) at each follow-up, which was significantly greater in cases than in controls (p = 0.001). CONCLUSIONS The current study demonstrates that the use of a flexion spacer significantly improves radiographic patello-femoral tracking, although no significant clinical differences were found between the two groups. LEVEL OF EVIDENCE Case-control study, level III.
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Patellar facet ratio affects knee pain, stair climbing and stair descent after TKA without patellar resurfacing. Knee Surg Sports Traumatol Arthrosc 2020; 28:3796-3804. [PMID: 31989190 DOI: 10.1007/s00167-020-05868-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/17/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE To determine whether knee pain or functional impairment after total knee arthroplasty (TKA) without patellar resurfacing are correlated with preoperative patellar morphology or postoperative patellar orientation. The hypotheses were that patellar shape, increased tilt and lateral displacement would be associated with pain and functional impairment. METHODS From a consecutive series of 152 knees that received a cemented postero-stabilized TKA, the Oxford Knee Score (OKS) and the Knee injury and Osteoarthritis Outcome Score (KOOS) were collected at a minimum follow-up of 12 months. Uni- and multi-variable linear regression analyses were performed to determine associations between the collected clinical scores and patient demographics and patellar morphology, measured from pre- and post-operative frontal, lateral and skyline view radiographs. RESULTS The OKS was 75 ± 23, whereas the KOOS pain, stair climbing, and descent were respectively 77 ± 24, 3.9 ± 1.1 and 3.8 ± 1.2. OKS was not associated with any radiographic outcomes, whereas KOOS pain was better for knees with larger medial patellar facets. The KOOS stair climbing and descent were also better for knees with larger medial patellar facets. CONCLUSION The findings of this study partly confirm the hypotheses that pain and functional impairments after TKA without patellar resurfacing are associated with patellar shape. No association was revealed between postoperative patellar orientation and function nor pain. Quantitative consideration of patellar congruency could therefore prevent pain and improve function after TKA without patellar resurfacing. LEVEL OF EVIDENCE Retrospective study, Level III.
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Kim CW, Lee CR, Huh TY. The effect of patellar facet angle on patellofemoral alignment and arthritis progression in posterior-stabilized total knee arthroplasty without patellar resurfacing. Knee Surg Relat Res 2020; 32:29. [PMID: 32660603 PMCID: PMC7285713 DOI: 10.1186/s43019-020-00045-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/11/2020] [Indexed: 12/17/2022] Open
Abstract
Background The purpose of this study was to evaluate the effect of patellar facet angle on pre- and postoperative patellofemoral alignment and the progress of arthritis of the patellofemoral joint in posterior-stabilized total knee arthroplasty (PS TKA) without patellar resurfacing. Methods Patients who had a PS TKA for a varus osteoarthritic knee who were followed up for more than 2 years were included in this study. The radiologic and clinical outcomes were compared between 72 knees (group A) whose patellar facet angle was greater than 126° (> 126°) and 32 knees (group B) whose patellar facet angle was smaller than or equal to 126° (≤ 126°). For the radiologic assessment, the Kellgren-Lawrence grade, mechanical femorotibial angle, Insall-Salvati ratio, patellar tilt angle, patellar displacement and the osteosclerosis of the patellar ridge were evaluated. The range of motion (ROM) and patient-reported outcomes (the Knee Society knee score, the Knee Society function score, the Feller patellar score, and the Kujala patellofemoral score) were used for the clinical assessment. Results The preoperative patellar tilt angle was 9.8° (standard deviation [SD] 5.5) and 14.6° (SD 4.1) in group A and group B, respectively, a significant difference (p < 0.001). Other preoperative radiologic parameters and preoperative patient-reported outcomes and ROM showed no significant difference between the two groups (all parameters (p > 0.05). At the last-follow-up, 22 knees (30.6%) showed progression of osteosclerosis of the patellar ridge in group A and 13 knees (40.6%) showed progression of osteosclerosis in group B (p = 0.371). The postoperative radiologic and clinical outcomes showed no significant difference between the two groups (all parameters, p > 0.05). Conclusions Although a narrow patellar facet angle was related to an increase of lateral tilting of the patella, it showed no impact on the preoperative clinical assessment. The radiologic and clinical outcomes evaluated after the PS TKA showed no statistical difference according to the patellar shape. Although the patellar shape evaluated by the patellar facet angle can partially affect the preoperative patellofemoral alignment, this study result indicated insignificant clinical relevance of the patellar shape in the PS TKA.
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Affiliation(s)
- Chang-Wan Kim
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, 75, Bokji-ro, Busanjin-gu, Busan, 47392, South Korea
| | - Chang-Rack Lee
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, 75, Bokji-ro, Busanjin-gu, Busan, 47392, South Korea.
| | - Tae-Yung Huh
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, 75, Bokji-ro, Busanjin-gu, Busan, 47392, South Korea
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Huang YF, Gao YH, Ding L, Liu B, Liu JG, Qi X. Influence of femoral implant design modification on anterior knee pain and patellar crepitus in patients who underwent total knee arthroplasty without patella resurfacing. BMC Musculoskelet Disord 2020; 21:364. [PMID: 32517681 PMCID: PMC7285730 DOI: 10.1186/s12891-020-03391-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
Background The incidence of patient dissatisfaction due to anterior knee pain (AKP) and patellar crepitus after total knee arthroplasty (TKA) remains a concern. However, it has been shown that improvements in the femoral component of traditional prostheses could reduce these instances of pain in the case of TKA performed with patellar resurfacing. This study aims to investigate whether TKA without patellar resurfacing can also benefit from the aforementioned femoral component modification in reducing AKP and patellar crepitus post-TKA. Methods Sixty-two patients (85 knees) who underwent TKA using the modern prosthesis and 62 age- and sex-matched patients (90 knees) fitted with the traditional prosthesis were enrolled in this study. The occurrence of AKP and patellar crepitus as well as the Knee Society Score (KSS) were consequently recorded, and the data was analyzed in order to determine whether there was a statistically significant difference between the two groups. Results The incidence of AKP was significantly lower in the study group compared with the control group at the 3-month and 1-year follow-ups (4.7% vs. 13.3% [p = 0.048] and 3.5% vs. 13.3% [p = 0.021], respectively). In addition, the incidence of patellar crepitus was also significantly lower in the study group compared with the control group at the 3-month and 1-year follow-ups (15.3% vs. 34.4% [p = 0.004] and 10.6% vs. 28.9% [p = 0.002], respectively). There was no significant difference in the KSS between the two groups. Conclusions These results revealed that TKA without patellar resurfacing will indeed benefit from the modified femoral implant design in reducing AKP and patellar crepitus, a finding that may be beneficial to surgeons who select implants for their patients when patellar resurfacing is not planned or not possible due to other reasons.
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Affiliation(s)
- Yi-Fan Huang
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Yu-Hang Gao
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Lu Ding
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Bo Liu
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Jian-Guo Liu
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Xin Qi
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China.
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Butnaru M, Sigonney G, Müller JH, Senioris A, Saffarini M, Courage O. Wiberg Type III patellae and J-sign during extension compromise outcomes of total knee arthroplasty without patellar resurfacing. Knee 2020; 27:787-794. [PMID: 32563437 DOI: 10.1016/j.knee.2020.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/20/2020] [Accepted: 04/06/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Understanding the risk factors associated with postoperative pain and worse outcome can guide surgeons on whether primary patellar resurfacing is warranted during total knee arthroplasty (TKA). The purpose of this study was to determine whether clinical scores and pain after TKA without patellar resurfacing are correlated with patellar shape and postoperative patellar position and kinematics. METHODS Radiographs as well as anterior knee pain according to the Visual Analogue Scale (pVAS) were collected pre- and postoperatively for 100 knees aged 68 ± 7.7 years that received uncemented TKA without patellar resurfacing. At a minimum follow-up of 12 months the Forgotten Joint Score (FJS), the Oxford Knee Score (OKS) as well as the flexion range of motion and the presence of J-sign during active extension were recorded. Uni- and multivariable linear regression analyses were performed to determine associations between the collected clinical scores and patient demographic and radiographic data. RESULTS Postoperative OKS (79 ± 14.4) was worse for Wiberg Type III patellae (β = -11.4, P = .020, compared with Type II). Anterior pVAS (2 ± 2) was greater in knees with J-sign during extension (β = 2.8, P < .001). None of the other radiographic measurements (patellar tilt, congruence angle and lateral patellar displacement) were correlated with postoperative OKS or anterior pVAS. CONCLUSION Incongruent patellar shape (Wiberg Type III) is associated with worse clinical scores, and abnormal kinematics (J-sign) with increased pain after TKA without patellar resurfacing. The authors therefore recommend routine resurfacing for Wiberg Type III patellae, though further studies are required to confirm whether resurfacing truly improves clinical scores and pain in this subgroup.
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Affiliation(s)
- Michaël Butnaru
- Ramsay Santé, Hôpital Privé de l'Estuaire, Le Havre, France; Department of Orthopaedic Surgery, Rouen University Hospital, Rouen, France
| | | | | | - Antoine Senioris
- Ramsay Santé, Hôpital Privé de l'Estuaire, Le Havre, France; Department of Orthopaedic Surgery, Rouen University Hospital, Rouen, France
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Nikkhoo M, Hassani K, Tavakoli Golpaygani A, Karimi A. Biomechanical role of posterior cruciate ligament in total knee arthroplasty: A finite element analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 183:105109. [PMID: 31606558 DOI: 10.1016/j.cmpb.2019.105109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/17/2019] [Accepted: 10/01/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The knee joint is a complex structure which is vulnerable to injury due to various types of loadings as a consequence of walking, running, stair climbing, etc. Total knee arthroplasty (TKA) is a widely used and successful orthopedic procedure which during that the posterior cruciate ligament (PCL) can either be retained or substituted. Different surgical techniques suggest retention or sacrifice of the PCL in TKA for the treatment of osteoarthritis which may alter the post-op outcomes. The objective of this study was to evaluate the biomechanical role of PCL after TKA surgery using finite element (FE) modeling. METHODS A three-dimensional (3D) FE model of the prosthetic knee was developed and its validity was compared to available studies in literature. Further, the effect of the retention or removing of the PCL as well as its degradation (i.e. variation in mechanical properties) and angle on knee biomechanics were evaluated during a weight-bearing squatting movement. RESULTS The validity of the intact model were confirmed. The results revealed higher stresses in the PCL and tibial insert at higher femoral flexion angles. In addition, the effect of variations in the stiffness of the PCL was found to be negligible at lower while considerable at higher femoral flexion angles. The variations in the elevation angle of the PCL from 89° to 83° at the critical femoral angles of 60° and 120° showed the highest von Mises stresses in the tibial insert. CONCLUSIONS The results have implications not only for understanding the stresses in the prosthetic knee model under squat movement but also for providing comprehensive information about the effects of variations in the PCL stiffness and balancing on the induced stresses of the PCL and tibial insert.
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Affiliation(s)
- Mohammad Nikkhoo
- Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Kamran Hassani
- Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran.
| | | | - Alireza Karimi
- Department of Mechanical Engineering, Kyushu University, 744 Motooka, Nishi-ku, Fukuoka 819-0395, Japan
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