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Dragosloveanu S, Capitanu BS, Josanu R, Vulpe D, Cergan R, Scheau C. Radiological Assessment of Coronal Plane Alignment of the Knee Phenotypes in the Romanian Population. J Clin Med 2024; 13:4223. [PMID: 39064265 PMCID: PMC11277824 DOI: 10.3390/jcm13144223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/14/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The Coronal Plane Alignment of the Knee (CPAK) classification system has been developed as a comprehensive framework delineating nine coronal plane phenotypes, based on arithmetic hip-knee angle (aHKA) and joint line obliquity (JLO). Our study aimed to assess the prevalence of knee phenotypes in the Romanian population using the CPAK classification, encompassing both osteoarthritic and healthy cohorts. Methods: We conducted an observational cross-sectional study, analyzing data from 500 knees with osteoarthritis and 500 healthy knees that met the inclusion criteria. Demographic data were collected, and radiological parameters including lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), aHKA, and JLO were measured. Knee phenotypes were categorized using the CPAK classification. Results: In the osteoarthritic cohort, the most prevalent CPAK phenotype was type I (42.4%), characterized by varus alignment and an apex distal joint. Conversely, in the healthy population, CPAK type II, indicating neutral alignment and an apex distal joint, was the most prevalent phenotype (39.0%). CPAK types VII, VIII, and IX were rare. Conclusions: Our findings demonstrate similarities in knee phenotypes compared to other populations, with some minor differences and particularities. The CPAK classification proves to be a valuable tool in assessing knee tyalignment.
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Affiliation(s)
- Serban Dragosloveanu
- Department of Orthopaedics and Traumatology, The “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Orthopaedics, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Bogdan-Sorin Capitanu
- Department of Orthopaedics, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Radu Josanu
- Department of Orthopaedics, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Diana Vulpe
- Department of Orthopaedics, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Romica Cergan
- Department of Anatomy, The “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Radiology and Medical Imaging, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Cristian Scheau
- Department of Radiology and Medical Imaging, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
- Department of Physiology, The “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Franceschetti E, Campi S, Giurazza G, Tanzilli A, Gregori P, Laudisio A, Hirschmann MT, Samuelsson K, Papalia R. Mechanically aligned total knee arthroplasty does not yield uniform outcomes across all coronal plane alignment of the knee (CPAK) phenotypes. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38984905 DOI: 10.1002/ksa.12349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE Patient dissatisfaction rates following total knee arthroplasty (TKA) reported in the literature reach 20%. The optimal coronal alignment is still under debate. The aim of this retrospective study was to compare clinical outcomes in different coronal plane alignment of the knee (CPAK) phenotypes undergoing mechanically aligned (MA) TKA. The hypothesis was that knees with preoperative varus arithmetic hip-knee-ankle angle (aHKA) would achieve inferior clinical outcomes after surgery compared to other aHKA categories. Additionally, another objective was to assess CPAK phenotypes distribution in the study population. METHODS A retrospective selection was made of 180 patients who underwent MA TKA from April 2021 to December 2022, with a 1-year follow-up. Coronal knee alignment was classified according to the CPAK classification. Clinical outcome evaluations were measured using the Knee Society Score (KSS), Oxford Knee Score (OKS), Short Form Survey 12 and Forgotten Joint Score (FJS). Differences in clinical outcomes were considered statistically significant with a p value <0 .05. RESULTS Patients with varus aHKA achieved significantly inferior outcomes at final follow-up compared to other aHKA categories in KSS pt. 1 (79.7 ± 17.2 vs. 85.6 ± 14.7; p = 0.028), OKS (39.2 ± 9.2 vs. 42.2 ± 7.2; p = 0.019) and FJS (75.4 ± 31.0 vs. 87.4 ± 22.9; p =0 .003). The most common aHKA category was the varus category (39%). The most common CPAK phenotypes were apex distal Types I (23.9%), II (22.8%) and III (13.3%). CONCLUSION MA TKA does not yield uniform outcomes across all CPAK phenotypes. Varus aHKA category shows significantly inferior results at final follow-up. The most prevalent CPAK categories are varus aHKA and apex distal JLO, with phenotypes I, II and III being the most common. However, their gender distribution varies significantly. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Edoardo Franceschetti
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Stefano Campi
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Giancarlo Giurazza
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Andrea Tanzilli
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Pietro Gregori
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Alice Laudisio
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
- University of Basel, Basel, Switzerland
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Rocco Papalia
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
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Arai N, Toyooka S, Masuda H, Kawano H, Nakagawa T. Kinematic Alignment Achieves a More Balanced Total Knee Arthroplasty Than Mechanical Alignment among CPAK Type I Patients: A Simulation Study. J Clin Med 2024; 13:3596. [PMID: 38930125 PMCID: PMC11204712 DOI: 10.3390/jcm13123596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/01/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Background: There is no consensus on whether mechanical alignment (MA) or kinematic alignment (KA) should be chosen for total knee arthroplasty (TKA) for coronal plane alignment of the knee (CPAK) Type I with a varus arithmetic HKA (aHKA) and apex distal joint line obliquity (JLO). The aim of this study was to investigate whether MA or KA is preferable for soft tissue balancing in TKA for this phenotype. Method: This prospective cohort study included 64 knees with CPAK Type I osteoarthritis that had undergone cruciate-retaining TKA. Using optical tracking software, we simulated implant placement in the Mako system before making the actual bone cut and compared the results between MA and KA. Extension balance (the difference between medial and lateral gaps in extension) and medial balance (the difference in medial gaps in flexion and extension) were examined. These gap differences within 2 mm were defined as good balance. Achievement of overall balance was defined as an attainment of good extension and medial balance. The incidence of balance in each patient was compared with an independent sample ratio test. Results: Compared with the MA group, the KA group achieved better soft tissue balance in extension balance (p < 0.001). A total of 75% of the patients in the KA group achieved overall balance, which was greater than the 38% achieved in the MA group (p < 0.001). Conclusions: In robot-assisted TKA for CPAK Type I osteoarthritis, KA achieved knee balance during extension without soft tissue release in a greater percentage of patients than MA.
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Affiliation(s)
| | | | | | | | - Takumi Nakagawa
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo 173-8606, Japan; (N.A.)
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MacDessi SJ, van de Graaf VA, Wood JA, Griffiths-Jones W, Bellemans J, Chen DB. Not all knees are the same. Bone Joint J 2024; 106-B:525-531. [PMID: 38821506 DOI: 10.1302/0301-620x.106b6.bjj-2023-1292.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
The aim of mechanical alignment in total knee arthroplasty is to align all knees into a fixed neutral position, even though not all knees are the same. As a result, mechanical alignment often alters a patient's constitutional alignment and joint line obliquity, resulting in soft-tissue imbalance. This annotation provides an overview of how the Coronal Plane Alignment of the Knee (CPAK) classification can be used to predict imbalance with mechanical alignment, and then offers practical guidance for bone balancing, minimizing the need for soft-tissue releases.
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Affiliation(s)
- Samuel J MacDessi
- CPAK Research Group, Sydney, Australia
- School of Clinical Medicine, University of NSW Medicine and Health, Sydney, Australia
- Sydney Knee Specialists, Kogarah, Australia
| | | | - Jil A Wood
- Sydney Knee Specialists, Kogarah, Australia
| | | | - Johan Bellemans
- CPAK Research Group, Sydney, Australia
- University Hasselt, ZOL Hospitals Genk, ArthroClinic Leuven, Leuven, Belgium
| | - Darren B Chen
- CPAK Research Group, Sydney, Australia
- Sydney Knee Specialists, Kogarah, Australia
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Palanisamy Y, Natarajan S, Prasad AR, Rajan DV. Coronal Plane Alignment Classification of Arthritic Knees in a South Indian Population and Functional Outcome Comparison Post-mechanical Alignment Total Knee Arthroplasty. Indian J Orthop 2024; 58:740-746. [PMID: 38812860 PMCID: PMC11130099 DOI: 10.1007/s43465-024-01154-y] [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: 12/18/2023] [Accepted: 04/11/2024] [Indexed: 05/31/2024]
Abstract
Study Background Mechanical alignment has always been considered as the gold standard in total knee arthroplasty (TKA), but various other coronal alignment strategies have been proposed to enhance native knee kinematics and thus elevate patient satisfaction levels. Coronal plane alignment of the knee (CPAK) classification introduced by MacDessi is a simple yet comprehensive system to classify knees based on their coronal plane alignment. It categorizes knees into nine phenotypes based on medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA). Materials and Methods This study investigates the distribution of classification of primary arthritic knees (CPAK) types among arthritic knees in the South Indian population and compares the functional outcomes following total knee arthroplasty (TKA) using traditional mechanical alignment among various CPAK types. The research, spanning from September 2021 to August 2023, encompasses a comprehensive analysis of 324 patients with 352 knees in the first part and 48 patients with 72 knees in the second part of the study who underwent TKA, incorporating demographic data and radiological evaluations. Results Results indicate a predominant distribution of CPAK type 1, followed by type 2 and type 4 among the South Indian population. In the functional outcomes analysis, regardless of CPAK type, patients exhibited significant improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), and visual analog scale (VAS) scores post-operatively. Conclusion CPAK distribution among the South Indian population is comparable to other Indian study and studies with an Asian population, but varies with studies among the White population. Significant improvement of functional outcome among all CPAK types signifies the robust nature of conventional mechanical alignment strategy. Thus, our study serves as an initial exploration into the knee phenotype of the South Indian population and findings contribute to ongoing research on optimal alignment strategies in knee arthroplasty, paving the way for future, more extensive studies in this dynamic field.
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Affiliation(s)
| | - Sugumar Natarajan
- Ortho-One Orthopaedic Speciality Centre, Coimbatore, 641005 Tamilnadu India
| | - Arjun R. Prasad
- Ortho-One Orthopaedic Speciality Centre, Coimbatore, 641005 Tamilnadu India
| | - David V. Rajan
- Ortho-One Orthopaedic Speciality Centre, Coimbatore, 641005 Tamilnadu India
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Ten Noever de Brauw GV, Bayoumi T, Ruderman LV, Kerkhoffs GMMJ, Zuiderbaan HA, Pearle AD. Knees with isolated lateral compartment osteoarthritis show a substantial variability in functional knee phenotypes with demographic-specific variations: Phenotypic analysis of 305 knees. Knee 2024; 48:265-278. [PMID: 38820655 DOI: 10.1016/j.knee.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/03/2024] [Accepted: 05/01/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND The primary aim of this study was to assess and describe the phenotypic variation in the coronal plane of knees affected by isolated lateral compartment osteoarthritis (OA). The secondary aim was to investigate the potential gender-specific and age-related differences in functional knee phenotypes among knees with isolated lateral compartment OA. METHODS A comprehensive classification system was used to categorize 305 knees with isolated lateral compartment OA based on their mechanical hip-knee-ankle angle (HKA), femoral mechanical angle (FMA), and tibial mechanical angle (TMA). The phenotypic variation of functional knee phenotypes was assessed for the entire cohort and stratified by gender and age category. RESULTS Among knees with isolated lateral compartment OA, a total of 60 distinct functional knee phenotypes were identified, with phenotype VALHKA6°NEUFMA0°VALTMA3° being the most prevalent (10.8 %). Gender-specific differences were evident, with females exhibiting significantly greater valgus alignment in both mean HKA and TMA values compared with males (HKA: -6.4° vs. -5.4°, respectively; P = 0.02 and TMA 94.4° vs. 89.0°, respectively; P = 0.005). Age-related variations included younger patients predominantly displaying femoral deformities, while older patients primarily exhibited isolated tibial- or combined femoral and tibial deformities. CONCLUSIONS There is a broad variation of functional knee phenotypes among knees affected by isolated lateral compartment OA, with gender-specific and age-related differences. Recognizing this inherent phenotypic diversity during preoperative planning may facilitate the implementation of tailored approaches that account for the unique characteristics and bony deformities of the individual knee.
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Affiliation(s)
- G V Ten Noever de Brauw
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center & Sports Medicine, Weill Medical College of Cornell University, New York, NY, USA; Amsterdam UMC location University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam, the Netherlands.
| | - T Bayoumi
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center & Sports Medicine, Weill Medical College of Cornell University, New York, NY, USA; Amsterdam UMC location University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam, the Netherlands
| | - L V Ruderman
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center & Sports Medicine, Weill Medical College of Cornell University, New York, NY, USA
| | - G M M J Kerkhoffs
- Amsterdam UMC location University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam, the Netherlands; Amsterdam Movement Sciences, Sports, Amsterdam, the Netherlands
| | - H A Zuiderbaan
- Medische Kliniek Velsen, Department of Orthopaedic Surgery, Velsen-Noord, the Netherlands
| | - A D Pearle
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center & Sports Medicine, Weill Medical College of Cornell University, New York, NY, USA
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Yang HY, Yoon TW, Kim JY, Seon JK. Radiologic Assessment of Knee Phenotypes Based on the Coronal Plane Alignment of the Knee Classification in a Korean Population. Clin Orthop Surg 2024; 16:422-429. [PMID: 38827768 PMCID: PMC11130633 DOI: 10.4055/cios23250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/21/2023] [Accepted: 10/21/2023] [Indexed: 06/05/2024] Open
Abstract
Background The Coronal Plane Alignment of the Knee (CPAK) classification system has been developed as a comprehensive system that describes 9 coronal plane phenotypes based on constitutional limb alignment and joint line obliquity (JLO). Due to the characteristics of Asian populations, which show more varus and wider distribution in lower limb alignment than other populations, modification of the boundaries of the arithmetic hip-knee-ankle angle (aHKA) and JLO should be considered. The purpose of this study was to determine the knee phenotype in a Korean population based on the original CPAK and modified CPAK classification systems. Methods We reviewed prospectively collected data of 500 healthy and 500 osteoarthritic knees between 2021 and 2023 using radiographic analysis and divided them based on the modified CPAK classification system by widening the neutral boundaries of the aHKA to 0° ± 3° and using the actual JLO as a new variable. Using long-leg standing weight-bearing radiographs, 6 radiographic parameters were measured to evaluate the CPAK type: the mechanical HKA angle, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), aHKA, JLO, and actual JLO. Results From 2 cohorts of 1,000 knees, the frequency distribution representing all CPAK types was different between the healthy and arthritic groups. The most common categories were type II (38.2%) in the healthy group and type I (53.8%) in the arthritic group based on the original CPAK classification. The left and upward shift in the distribution of knee phenotypes in the original classification was corrected evenly after re-establishing the boundaries of a neutral aHKA and the actual JLO. According to the modified CPAK classification system, the most common categories were type II (35.2%) in the healthy group and type I (38.0%) in the arthritic group. Conclusions Although the modified CPAK classification corrected the uneven distribution seen when applying the original classification system in a Korean population, the most common category was type I in Korean patients with osteoarthritic knees in both classification systems. Furthermore, there were different frequencies of knee phenotypes among healthy and arthritic knees.
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Affiliation(s)
- Hong Yeol Yang
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Tae Woong Yoon
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Joon Yeong Kim
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Jong Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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Liu L, Lei K, Du D, Lin Y, Pan Z, Guo L. Functional knee phenotypes appear to be more suitable for the Chinese OA population compared with CPAK classification: A study based on 3D CT reconstruction models. Knee Surg Sports Traumatol Arthrosc 2024; 32:1264-1274. [PMID: 38488258 DOI: 10.1002/ksa.12130] [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: 11/10/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 04/23/2024]
Abstract
PURPOSE The aim of this study was to investigate the distribution of coronal plane alignment of the knee (CPAK) classification and functional knee phenotypes in a Chinese osteoarthritis (OA) population and to compare different lower limb alignment targets according to the distribution characteristics to find suitable total knee arthroplasty (TKA) bone cut strategies for the Chinese OA patients. METHODS The computed tomography (CT) images were retrospectively collected and the three-dimensional (3D) models were reconstructed from 434 Chinese OA patients, including 93 males and 341 females, with a mean age of 66.4 ± 9.3 years. Femoral mechanical angle (FMA), tibial mechanical angle (TMA) and mechanical hip-knee-ankle angle (mHKA) were measured on the 3D models. Arithmetic hip-knee-ankle angle (aHKA) was calculated using FMA plus TMA, and joint line obliquity was calculated as 180 + TMA-FMA. The CPAK according to MacDessi and the functional knee phenotypes according to Hirschmann were performed. In addition, the suitable TKA bone cut strategies were explored according to the phenotypes and based on the characteristics of different alignment targets, such as mechanical alignment, anatomic alignment (AA), kinematic alignment, restricted KA (rKA) and adjusted MA (aMA). Statistical differences were determined using the independent-samples t-test or the two independent-samples Wilcoxon test, with p < 0.05 considered statistically significant. RESULTS The Chinese OA population showed a varus alignment tendency (mHKA = 172.1° ± 7.2°), to which the TMA was a major contributor (TMA = 84.7° ± 4.4° vs. FMA = 91.3° ± 3.2°). The mHKA was on average 3.9° more varus than the aHKA. A total of 140 functional knee phenotypes were found and 45.6% were concentrated in VARFMA3°-NEUFMA0° to VARTMA3°-NEUTMA0°. More than 70% of patients had different FMA and TMA phenotypes. There were 92.9% of CPAK distributed in types I to IV, with type I accounting for 53.9%. The FMA phenotypes were less changed if the aMA and rKA were chosen, and the TMA phenotypes were less changed if the AA and rKA were chosen. CONCLUSION Compared with the CPAK, the functional knee phenotypes were more suitable for the Chinese OA population with a wide distribution and a varus tendency, and it seemed more appropriate to choose aMA and rKA as TKA alignment targets for resection. LEVEL OF EVIDENCE Level Ⅲ.
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Affiliation(s)
- LiMing Liu
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Kai Lei
- Sports Medicine Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dekai Du
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Yong Lin
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Zhaoxun Pan
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Lin Guo
- Sports Medicine Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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Ziegenhorn J, Kirschberg J, Heinecke M, von Eisenhart-Rothe R, Matziolis G. Significant difference in femoral torsion between coronal plane alignment of the knee type 1 and 4. Knee Surg Sports Traumatol Arthrosc 2024; 32:1199-1206. [PMID: 38511851 DOI: 10.1002/ksa.12149] [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: 12/05/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE The purpose of this study was to find out whether the torsions of the femur and tibia are dependent on the coronal plane alignment of the knee (CPAK) type. METHODS Five hundred patients (1000 legs) were included, who received a whole leg standing three-dimensional (3D) radiograph using EOS imaging (EOS Imaging, Paris, France). SterEOS software was used for digital reconstruction. Femoral and tibial torsions were determined by analysing 3D reconstructions of each leg. Femoral torsion was defined as the angle between the femoral neck axis (FNA) and the posterior condylar axis (PCA). Tibial torsion was defined as the angle between the axis tangent to the posterior part of the tibia plateau and the transmalleolar axis. Arithmetic hip-knee-ankle angle (aHKA) and joint-line obliquity (JLO) were also determined, allowing each leg to be assigned one of nine possible phenotypes according to CPAK. RESULTS The mean femoral torsion in CPAK type 1 was significantly higher (+ 2.6° ± 0.8°) than in CPAK type 4 (p = 0.02). All other CPAK types did not differ in the degree of femoral torsions. No differences could be demonstrated for the tibial torsion. CONCLUSION There is a correlation between the coronal alignment of the lower limb and femoral torsion. This may provide the basis for extending the CPAK classification beyond the coronal plane. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jonas Ziegenhorn
- Orthopaedic Department, University Hospital Jena, Campus Eisenberg, Germany
| | - Julia Kirschberg
- Orthopaedic Department, University Hospital Jena, Campus Eisenberg, Germany
- German Knee Society (DKG), Munich, Germany
| | - Markus Heinecke
- Orthopaedic Department, University Hospital Jena, Campus Eisenberg, Germany
- German Knee Society (DKG), Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- German Knee Society (DKG), Munich, Germany
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Georg Matziolis
- Orthopaedic Department, University Hospital Jena, Campus Eisenberg, Germany
- German Knee Society (DKG), Munich, Germany
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Gao YH, Qi YM, Huang PH, Zhao XY, Qi X. Distribution of coronal plane alignment of the knee classification in Chinese osteoarthritic and healthy population: a retrospective cross-sectional observational study. Int J Surg 2024; 110:2583-2592. [PMID: 38349219 DOI: 10.1097/js9.0000000000001178] [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: 12/06/2023] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Few studies have reported the coronal constitutional alignment of the lower limbs in mainland China. This study aimed to analyse the distribution of the coronal plane alignment of the knee (CPAK) classification in the osteoarthritic (OA) and healthy Chinese populations. MATERIALS AND METHODS The CPAK distributions of 246 patients (477 knees) with OA and 107 healthy individuals (214 knees) were retrospectively examined using long-leg radiographs. Radiological measurements and CPAK classification of different Kellgren-Lawrence grades in patients with unilateral total knee arthroplasty (TKA) were compared. The clinical outcomes of patients with CPAK type I who underwent mechanical alignment or restricted kinematic alignment during TKA were examined. RESULTS The most common distributions in the OA and healthy groups were type I and type II, respectively. In patients who underwent unilateral TKA, the most common distribution of knees graded as Kellgren-Lawrence 3-4 was type I. However, the most common distributions of contralateral knees graded as Grade 0-2 were type I and II. For patients with CPAK type I, the mechanical alignment and restricted kinematic alignment groups did not differ significantly concerning postoperative clinical outcomes at 3 months. CONCLUSION The most common distributions in Chinese osteoarthritic and healthy populations were types I and II, respectively. In addition, OA progression may lead to changes in the CPAK classification.
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Affiliation(s)
- Yu-Hang Gao
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yu-Meng Qi
- Departments of Biostatistics, Columbia University, New York, NY, USA
| | - Pei-Hong Huang
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xing-Yu Zhao
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xin Qi
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
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Won SH, Eim SH, Shen QH, Kim KK, Won YY. Caliper-verified unrestricted kinematically aligned total knee arthroplasty in Asian patients showed efficacious mid- to long-term results regardless of postoperative alignment categories. Knee Surg Sports Traumatol Arthrosc 2024; 32:941-952. [PMID: 38461403 DOI: 10.1002/ksa.12117] [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: 09/22/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE There have been insufficient data regarding the long-term results of unrestricted kinematically aligned total knee arthroplasty (unKATKA) in Asian patients. We investigated mid- to long-term clinical and radiological follow-up data of Korean patients after caliper-verified unKATKA of minimum 7.4-10 years including categorised data of postoperative tibial component, limb and knee alignment. Additionally, we analysed the preoperative distribution and postoperative restoration of coronal plane alignment of knee (CPAK) phenotypes. METHODS This study is a retrospective analysis of 63 patients: 96 osteoarthritic underwent consecutive caliper-verified unKATKA between October 2013 and May 2016 by a single surgeon. Implant survivorship was investigated for revision for any reason. Each knee was categorised into an in-range or outlier group by three postoperative alignment parameters: tibial component, knee and limb alignment. Statistical analyses were done for any significant differences in clinical scores and implant survival rates between groups. Finally, all knees were classified into CPAK classification postoperatively and postoperatively. The CPAK restoration rate was calculated. RESULTS Among 85 knees in the clinically confirmed group, implant survival was 98.8%. There was one case of revision due to periprosthetic fracture. The percentage postoperatively aligned in the varus (valgus) outlier range was 100% (0%) for tibial component, 16.7% (24.8%) for the knee alignment and 51% (0%) for the limb alignment. All three categories did not affect implant survival or clinical scores. Eighty one out of 96 knees (84.4%) were restored to their CPAK phenotype postoperatively. CONCLUSION With the limitation of a case series having a small number of patients and gender deviation, our study suggests that caliper-verified unKATKA could be a good option regardless of geographical variation of constitutional alignment in patients with osteoarthritis (OA). LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Seok-Hyung Won
- Department of Orthopedic Surgery, Ajou University Medical Center, Suwon, South Korea
| | - Seong-Hyuk Eim
- Department of Orthopedic Surgery, Ajou University Medical Center, Suwon, South Korea
| | - Quan-Hu Shen
- Department of Orthopedic Surgery, The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, China
| | - Kwang-Kyoun Kim
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, South Korea
| | - Ye-Yeon Won
- Department of Orthopedic Surgery, Ajou University Medical Center, Suwon, South Korea
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12
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Tarassoli P, Warnock JM, Lim YP, Jagota I, Parker D. Large multiplanar changes to native alignment have no apparent impact on clinical outcomes following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2024; 32:432-444. [PMID: 38294963 DOI: 10.1002/ksa.12044] [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: 09/14/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE This study sought to examine if achieved postoperative alignment when compared to the native anatomy would lead to a difference in Patient Reported Outcome Measures (PROMs), and whether the achieved alignment could be broadly categorised by an accepted alignment strategy. METHODS A retrospective cohort study of prospectively collected data on patients undergoing single primary or bilateral simultaneous total knee arthroplasty (TKA) was carried out. CT scans were used to determine the mean change ("delta values") between the pre and postoperative; hip-knee-ankle angle, lateral distal femoral angle, medial proximal tibial angle and femoral implant rotation. Femoral implant flexion and tibial implant slope were measured postoperatively. The primary outcome was the relationship of the variables to the change in KOOS pain subscale after one year. The secondary outcome was the number of knees which could be categorised postoperatively to an alignment strategy, and the mean PROMs in each cohort. RESULTS A total of 296 knees in 261 patients were available for analysis. With regards to the primary outcome, the delta values for each variable did not demonstrate any association with the change in knee injury and osteoarthritis outcome score (KOOS) pain score. Approximately 46% of knees could not be categorised to an alignment strategy based on postoperatively measured alignment, with no significant difference between each cohort with regards to the change in KOOS Pain score. CONCLUSION Achieved alignment does not consistently match accepted alignment strategies, and appears to confer no benefit to clinical outcomes when the native anatomy is most closely approximated, nor results in poorer outcomes in outliers. This study highlights the importance of routine three dimensional pre and postoperative imaging in clinical practice and for the valid analysis of outcomes in studies on alignment. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Payam Tarassoli
- Sydney Orthopaedic Research Institute, St Leonards, Australia
| | | | - Yoong Ping Lim
- Sydney Orthopaedic Research Institute, St Leonards, Australia
- The University of Sydney, Camperdown, Australia
- Charles Darwin University, Casuarina, Australia
| | - Ishaan Jagota
- 360 Med Care Pty Ltd, Pymble, Australia
- Flinders University, Adelaide, Australia
| | - David Parker
- Sydney Orthopaedic Research Institute, St Leonards, Australia
- The University of Sydney, Camperdown, Australia
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Kobayashi T, Kawaguchi K, Goto K, Suzuki H, Otsu M, Michishita K. Functional knee phenotypes: A helpful classification tool for visualizing potential femoral varus in restricted kinematic alignment total knee arthroplasty in Japan. Knee Surg Sports Traumatol Arthrosc 2024; 32:103-115. [PMID: 38226677 DOI: 10.1002/ksa.12028] [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: 10/10/2023] [Revised: 11/29/2023] [Accepted: 12/02/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE Restricted kinematic alignment (rKA) is a modified technique of kinematically aligned total knee arthroplasty (TKA) within a safe alignment range for long-term implant survivorship. The purpose of this study was to clarify (1) the distribution of functional knee phenotypes in patients who underwent TKA in Japan and (2) whether the application of this classification results in anatomically neutral alignment after rKA TKA. METHODS Overall, 114 TKA surgeries (mechanical alignment [MA]: 49; rKA: 65) were performed. The joint line orientation angle (JLOA), hip-knee-ankle angle (HKA), femoral mechanical angle (FMA) and tibial mechanical angle (TMA) were obtained. The knees were categorized using a functional knee phenotype classification. Clinical evaluations, including the Knee Injury and Osteoarthritis Outcome, 12-question Forgotten Joint and Oxford Knee Scores, were performed 3 years postoperatively. Between-group comparisons were made. RESULTS The most common preoperative functional knee phenotype was VARHKA 3° + NEUFMA 0° + VARTMA 3° (11.4%). In the preoperative population, 51 knees (44.7%) had VARFMA ≥ 3°. Postoperatively, the most common functional knee phenotype was NEUHKA 0° + VARFMA 3° + VALTMA 3° (14 knees, 28.6%) in the MA and NEUHKA 0° + NEUFMA 0° + NEUTMA 0° in the rKA group. The percentage of postoperative JLOA within ±3° from the floor was 27% and 72% in the MA and rKA groups, respectively (p < 0.001). The functional knee phenotype after rKA TKA was neutrally reproduced, and the joint line was more parallel to the ground in the standing position than that of MA. Between-group differences in clinical outcomes were not significant. CONCLUSION The application of functional knee phenotyping to knee osteoarthritis in Japan suggested the presence of racial morphological characteristics. This classification could help better visualize potential femoral varus, contributing to protocol deviation in applying restricted KA TKA. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Takashi Kobayashi
- Department of Orthopedic Surgery, Yugawara Hospital, Yugawara, Kanagawa, Japan
| | - Kohei Kawaguchi
- Department of Orthopedic Surgery, Faculty of Medicine, The University of Tokyo, Bunkyo City, Tokyo, Japan
| | - Kazumi Goto
- Department of Sports Orthopedics Surgery, Kanto Rosai Hospital, Kawasaki, Kanagawa, Japan
| | - Hayata Suzuki
- Department of Orthopedic Surgery, Yugawara Hospital, Yugawara, Kanagawa, Japan
| | - Masayoshi Otsu
- Department of Orthopedic Surgery, Yugawara Hospital, Yugawara, Kanagawa, Japan
| | - Kazuhiko Michishita
- Department of Orthopedic Surgery, Yugawara Hospital, Yugawara, Kanagawa, Japan
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14
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Inui H, Yamagami R, Kono K, Kawaguchi K, Kage T, Murakami R, Nakamura H, Saita K, Taketomi S, Tanaka S. Short-term clinical results of bicruciate-retaining total knee arthroplasty using personalized alignment. BMC Musculoskelet Disord 2023; 24:965. [PMID: 38087214 PMCID: PMC10714564 DOI: 10.1186/s12891-023-07083-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Bicruciate-retaining (BCR) prosthesis has been introduced to recreate normal knee movement by preserving both the anterior and posterior cruciate ligaments. However, the use of BCR total knee arthroplasty (TKA) is still debatable because of several disappointing reports. We have been performing BCR TKAs with personalized alignment (PA). This study aimed to reveal the limb alignment and soft tissue balance of FA-BCR TKAs and compare the clinical outcomes of FA-BCR TKAs with those of unicompartmental knee arthroplasty (UKA). METHODS Fifty BCR TKAs and 58 UKAs were included in this study. The joint component gaps of BCR TKA were evaluated intraoperatively and the postoperative hip-knee-ankle (HKA) angle, medial proximal tibial angle (MPTA), and lateral distal femoral angle (LDFA) were measured using full-length standing radiography. The short-term clinical outcomes of BCR TKAs were compared with those of UKA using the scoring system of 2011 Knee Society Scoring (KSS) and the knee injury and osteoarthritis outcome score (KOOS) at an average of 2 years postoperatively (1-4yeras). RESULTS The coronal alignment values of PA-BCR TKA were as follows: HKA angle, 177.9° ± 2.3°; MPTA, 85.4° ± 1.9°; and LDFA, 87.5° ± 1.9°. The joint component gaps at flexion angles of 10°, 30°, 60°, and 90° were 11.1 ± 1.2, 10.9 ± 1.4, 10.7 ± 1.3, and 11.2 ± 1.4 mm for the medial compartment and 12.9 ± 1.5, 12.6 ± 1.8, 12.5 ± 1.8 and 12.5 ± 1.7 mm for the lateral compartment, respectively. The patient expectation score and maximum extension angle of PA-BCR TKA were significantly better than those of UKAs. CONCLUSIONS The short-term clinical outcomes of PA-BCR TKA were comparable or a slightly superior to those of UKAs.
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Affiliation(s)
- Hiroshi Inui
- Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8500, Japan.
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Ryota Yamagami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kenichi Kono
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kohei Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Tomofumi Kage
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ryo Murakami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Haruhiko Nakamura
- Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8500, Japan
| | - Kazuo Saita
- Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8500, Japan
| | - Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Nomoto K, Hanada M, Hotta K, Matsuyama Y. Distribution of coronal plane alignment of the knee classification does not change as knee osteoarthritis progresses: a longitudinal study from the Toei study. Knee Surg Sports Traumatol Arthrosc 2023; 31:5507-5513. [PMID: 37819599 DOI: 10.1007/s00167-023-07604-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/21/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE The purpose of this study was to investigate the coronal plane alignment of the knee (CPAK) phenotypes of individuals with knee osteoarthritis (OA) progression. We hypothesized that distributions of CPAK phenotypes would be similar throughout OA progression, despite arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) changing. METHODS A total of 248 patients (79 men and 169 women) participated in the first study in 2012 and the fifth study in 2020. Patients with progression of knee OA for eight years were included. Knee OA progression was defined as advancement from KL grade 0-2 to KL grade 3 or 4. Alignment parameters, including the aHKA, JLO, hip-knee-ankle angle (HKA), lateral distal femur angle (LDFA), medial proximal tibial angle (MPTA), and joint line convergence angle (JLCA), were measured. Changes in distribution of CPAK classifications and alignment parameters were investigated. Alignment parameters were compared using a paired t-test. Statistical significance was defined as p < 0.05. RESULTS The study included 48 patients (60 knees). The distributions of all CPAK phenotypes were similar between 2012 and 2020. MPTA (83.7° ± 2.8° vs. 82.3° ± 4.8°, p < 0.01), aHKA (- 3.6° ± 3.8° vs. - 4.9° ± 6.2°, p = 0.01), and JLO (171.1° ± 4.6° vs. 169.5° ± 5.1°, p < 0.01) decreased significantly, and JLCA (1.17° ± 2.2° vs. 3.1° ± 4.7°, p < 0.01) and HKA (4.8° ± 3.9° vs. 8.0° ± 5.4°, p < 0.01) increased significantly. In contrast, LDFA (87.4° ± 3.2° vs. 87.2° ± 3.1°, p = n.s.) did not change significantly. CONCLUSIONS The CPAK classification system can predict constitutional alignment, even with knee OA progression, and enables surgeons to perform individualized preoperative alignment planning according to knee phenotypes.
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Affiliation(s)
- Kazuki Nomoto
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Mitsuru Hanada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Kensuke Hotta
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
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16
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Ten Noever de Brauw GV, Bayoumi T, Ruderman LV, Kerkhoffs GMMJ, Pearle AD, Zuiderbaan HA. Knees with anteromedial osteoarthritis show a substantial phenotypic variation prior and following medial unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2023; 31:5579-5590. [PMID: 37848566 DOI: 10.1007/s00167-023-07603-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/21/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE The primary aim of this study was to evaluate the phenotypic variation using the Coronal Plane Alignment of the Knee (CPAK) classification among 1000 knees with anteromedial osteoarthritis (OA) both prior to and following medial unicompartmental knee arthroplasty (UKA). The secondary aim of this study was to investigate whether knees maintained their preoperative CPAK phenotype and to evaluate the phenotypic alterations following medial UKA. METHODS The CPAK classification was used to analyze 1000 knees that underwent medial UKA as treatment for anteromedial OA. Knees were categorized into nine distinct CPAK phenotypes based on their arithmetic hip-knee-ankle angle (aHKA), which estimates the pre-arthritic alignment, and joint line obliquity (JLO), both pre- and postoperatively. Phenotypic variation was analyzed by sex and age, and the phenotypic alterations following medial UKA were evaluated by phenotype. RESULTS Preoperatively, CPAK phenotype I had the highest prevalence (45.0%). Among males, the preoperative prevalence of CPAK phenotype I was significantly higher compared to females (53.2% vs. 35.0%, respectively; p ≤ .001), whereas females exhibited a significantly higher occurrence of CPAK phenotype V compared to males (9.8% vs. 4.4%, respectively; p ≤ .015). Following medial UKA, CPAK phenotype II had the highest prevalence (53.3%). Overall, 45.1% of knees maintained their preoperative CPAK phenotype following medial UKA, which was most frequently observed among CPAK phenotype II (67.7%) and III (65.8%). CONCLUSION There is a substantial variation in CPAK phenotypes among knees with anteromedial OA, as well as following treatment with medial UKA. This variability challenges the assumption of uniform characteristics among knees with an identical wear pattern associated with anteromedial OA and emphasizes the complexity and variability of this specific form of OA. LEVEL OF EVIDENCE III, Retrospective cohort study.
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Affiliation(s)
- G V Ten Noever de Brauw
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center and Sports Medicine, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA.
- Department of Orthopaedic Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - T Bayoumi
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center and Sports Medicine, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopaedic Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - L V Ruderman
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center and Sports Medicine, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA
| | - G M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Sports, Amsterdam, The Netherlands
| | - A D Pearle
- Hospital for Special Surgery, Department of Orthopaedic Surgery, Computer Assisted Surgery Center and Sports Medicine, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA
| | - H A Zuiderbaan
- Department of Orthopaedic Surgery, Medische Kliniek Velsen, Velsen-Noord, The Netherlands
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17
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Tarassoli P, Corban LE, Wood JA, Sergis A, Chen DB, MacDessi SJ. Long leg radiographs underestimate the degree of constitutional varus limb alignment and joint line obliquity in comparison with computed tomography: a radiographic study. Knee Surg Sports Traumatol Arthrosc 2023; 31:4755-4765. [PMID: 37490128 DOI: 10.1007/s00167-023-07505-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/05/2023] [Indexed: 07/26/2023]
Abstract
PURPOSE The purpose of this study was to understand if differences exist between computed tomography (CT) and long leg radiographs (LLR) when defining coronal plane alignment of the lower limb in total knee arthroplasty (TKA). It aimed to identify any such differences between the two imaging modalities by quantifying constitutional limb alignment (arithmetic hip-knee-ankle angle (aHKA), joint line obliquity (JLO) and Coronal Plane Alignment of the Knee (CPAK) type within the same population. METHODS A retrospective radiographic study compared pre-operative LLR and CT measurements in patients undergoing robotic-assisted TKA. The aHKA, JLO and CPAK types were calculated after measuring the medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA). The primary outcomes were the mean differences in aHKA (MPTA-LDFA), JLO (MPTA + LDFA) and proportions of CPAK types between LLR and CT groups. The secondary outcomes were the differences in CT-derived MPTA values based on four different tibial sagittal landmarks. RESULTS After exclusions, 465 imaging sets were analysed in 394 patients. There was a statistically significant mean difference between LLR and CT, respectively, for both MPTA (87.5° vs. 86.2°; p < 0.01) and LDFA (88.7° vs. 87.3°; p < 0.01). There were also statistically significant differences for aHKA (- 0.2° vs. - 1.1°) and JLO (175.1° vs. 173.4°) for LLR and CT, respectively (both p < 0.01). CT increased the proportion of patients with CPAK Type I (constitutional varus aHKA, apex distal JLO) and CPAK Type II (neutral aHKA, apex distal JLO), and decreased numbers of CPAK Types III-VI. There were significant mean differences in the MPTA using varying sagittal landmarks. CONCLUSION Alignment determined by LLRs underestimates the magnitude of both constitutional varus alignment and joint line obliquity compared to CT, differences that notably increase the proportions of patients included in CPAK Types I and II. These distinctions are primarily due to underestimation of proximal tibial varus when measured on LLRs compared to CT, which more specifically defines articular weight-bearing points. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Payam Tarassoli
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Luke E Corban
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Jil A Wood
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Andrew Sergis
- Stryker Australia, 8 Herbert St, St Leonards, NSW, 2065, Australia
| | - Darren B Chen
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
- St George Private Hospital, 1 South St, Kogarah, NSW, 2217, Australia
| | - Samuel J MacDessi
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia.
- St George Private Hospital, 1 South St, Kogarah, NSW, 2217, Australia.
- School of Clinical Medicine, University of New South Wales, St George and Sutherland Campuses, Sydney, NSW, Australia.
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18
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Huber S, Mitterer JA, Vallant SM, Simon S, Hanak-Hammerl F, Schwarz GM, Klasan A, Hofstaetter JG. Gender-specific distribution of knee morphology according to CPAK and functional phenotype classification: analysis of 8739 osteoarthritic knees prior to total knee arthroplasty using artificial intelligence. Knee Surg Sports Traumatol Arthrosc 2023; 31:4220-4230. [PMID: 37286901 DOI: 10.1007/s00167-023-07459-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/13/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE Osteoarthritis of the knee is commonly associated with malalignment of the lower limb. Recent classifications, as the Coronal Plane Alignment of the Knee (CPAK) and Functional Phenotype classification, describe the bony knee morphology in addition to the overall limb alignment. Data on distribution of these classifications is not sufficient in large populations. The aim of this study was to analyse the preoperative knee morphology with regard to the aforementioned classifications in long leg radiographs prior to total knee arthroplasty surgery using Artificial Intelligence. METHODS The cohort comprised 8739 preoperative long leg radiographs of 7456 patients of all total knee arthroplasty surgeries between 2009 and 2021 from our institutional database. The automated measurements were performed with the validated Artificial Intelligence software LAMA (ImageBiopsy Lab, Vienna) and included standardized axes and angles [hip-knee-ankle angle (HKA), mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibia angle (mMPTA), mechanical axis deviation (MAD), anatomic mechanic axis deviation (AMA) and joint line convergence angle (JLCA)]. CPAK and functional phenotype classifications were performed and all measurements were analysed for gender, age, and body mass index (BMI) within these subgroups. RESULTS Varus alignment was more common in men (m: 2008, 68.5%; f: 2953, 50.8%) while neutral (m: 578, 19.7%; f: 1357, 23.4%) and valgus (m: 345, 11.8%; f: 1498, 25.8%) alignment was more common in women. The most common morphotypes according to CPAK classification were CPAK Type I (2454; 28.1%), Type II (2383; 27.3%), and Type III (1830; 20.9%). An apex proximal joint line (CPAK Type VII, VIII and IX) was only found in 1.3% of all cases (n = 121). In men, CPAK Type I (1136; 38.8%) and CPAK Type II (799; 27.3%) were the most common types and women were spread more equally between CPAK Type I (1318; 22.7%), Type II (1584; 27.3%) and Type III (1494; 25.7%) (p < 0.001). The most common combination of femur and tibia types was NEUmLDFA0°,NEUmMPTA0° (m: 514, 17.5%; f: 1004, 17.3%), but men showed femoral varus more often. Patients with a higher BMI showed a significantly lower age at surgery (R2 = 0.09, p < 0.001). There were significant differences between men and women for all radiographic parameters (p < 0.001). CONCLUSION Distribution in knee morphology with gender-specific differences highlights the wide range in osteoarthritic knees, characterized by CPAK and phenotype classification and may influence future surgical planning. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Stephanie Huber
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
- Center for Anatomy and Cell Biology, Medical University Vienna Speising, Währinger Straße 13, 1090, Vienna, Austria
| | - Jennyfer A Mitterer
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Sascha M Vallant
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
- 2nd Department, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Florian Hanak-Hammerl
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Gilbert M Schwarz
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
- Center for Anatomy and Cell Biology, Medical University Vienna Speising, Währinger Straße 13, 1090, Vienna, Austria
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Antonio Klasan
- Department of Orthopedics and Trauma-Surgery, AUVA Trauma Hospital Graz, Göstinger Straße 26, 8020, Graz, Austria
- Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria.
- 2nd Department, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria.
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Mulpur P, Desai KB, Mahajan A, Masilamani ABS, Hippalgaonkar K, Reddy AVG. Radiological Evaluation of the Phenotype of Indian Osteoarthritic Knees based on the Coronal Plane Alignment of the Knee Classification (CPAK). Indian J Orthop 2022; 56:2066-2076. [PMID: 36507214 PMCID: PMC9705643 DOI: 10.1007/s43465-022-00756-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/15/2022] [Indexed: 02/04/2023]
Abstract
Background Understanding constitutional alignment of the lower limb is essential to optimize alignment strategies during total knee arthroplasty. The coronal plane alignment of knee (CPAK) classification system was proposed as a comprehensive assessment tool based on coronal alignment and variations in joint line obliquity (JLO). This prospective observational cross-sectional study aimed to evaluate the phenotype of knees in the Indian population based on the CPAK system. Methods Two cohorts of individuals (250 young healthy volunteers and 250 elderly patients with knee osteoarthritis) underwent radiological assessment with long-leg radiographs and were classified based on the CPAK system. Measurements included the mechanical and arithmetic hip-knee-ankle angles (mHKA, aHKA), joint line obliquity (JLO), lateral distal femoral angle (mLDFA) and medial proximal tibial angle (mMPTA). Knees were grouped into 9 CPAK phenotypes based on aHKA and JLO. Results A total of 1000 knees were evaluated. In cohort-1 of healthy young adults, most knees were distributed in the CPAK class II phenotype (128 knees, 25.6%) followed by CPAK Type I (106 knees, 21.2%). In cohort-2 of elderly arthritic adults, most knees were distributed in Type I (294 knees, 58.8%) with constitutional varus and apex-distal joint line orientation. Conclusion The majority of the study population was found to have constitutional varus alignment. In addition, a high proportion of patients in both categories, especially arthritic patients undergoing TKA, were found to have varus alignment with an apex-distal oblique joint line. This classification may help optimize component positioning to restore constitutional alignment and joint line orientation during TKA.
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Affiliation(s)
- Praharsha Mulpur
- Sunshine Bone and Joint Institute, Sunshine Hospitals, PG Road, opposite Parsi Dharamsala, Paradise, Sappu Bagh Apartments, Jogani, Ramgopalpet, Secunderabad, Hyderabad, Telangana 500003 India
| | - Keyur B. Desai
- Sunshine Bone and Joint Institute, Sunshine Hospitals, PG Road, opposite Parsi Dharamsala, Paradise, Sappu Bagh Apartments, Jogani, Ramgopalpet, Secunderabad, Hyderabad, Telangana 500003 India
| | - Aakarsh Mahajan
- Sunshine Bone and Joint Institute, Sunshine Hospitals, PG Road, opposite Parsi Dharamsala, Paradise, Sappu Bagh Apartments, Jogani, Ramgopalpet, Secunderabad, Hyderabad, Telangana 500003 India
| | - A. B. Suhas Masilamani
- Sunshine Bone and Joint Institute, Sunshine Hospitals, PG Road, opposite Parsi Dharamsala, Paradise, Sappu Bagh Apartments, Jogani, Ramgopalpet, Secunderabad, Hyderabad, Telangana 500003 India
| | - Kushal Hippalgaonkar
- Sunshine Bone and Joint Institute, Sunshine Hospitals, PG Road, opposite Parsi Dharamsala, Paradise, Sappu Bagh Apartments, Jogani, Ramgopalpet, Secunderabad, Hyderabad, Telangana 500003 India
| | - A. V. Gurava Reddy
- Sunshine Bone and Joint Institute, Sunshine Hospitals, PG Road, opposite Parsi Dharamsala, Paradise, Sappu Bagh Apartments, Jogani, Ramgopalpet, Secunderabad, Hyderabad, Telangana 500003 India
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