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Rajani AM, Mittal AR, Shah UA, Kulkarni VU, Dubey R, Rajani AA. Postero-Central Slice Osteotomy of the Proximal Tibia: A Novel Technique for Correcting Resistant Tight Extension Gaps in Posterior-Stabilized Total Knee Arthroplasty for Varus Osteoarthritis. J Arthroplasty 2024:S0883-5403(24)00835-0. [PMID: 39142614 DOI: 10.1016/j.arth.2024.08.012] [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: 04/24/2024] [Revised: 08/02/2024] [Accepted: 08/05/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND The aim of total knee arthroplasty (TKA) is to circumvent the pain due to advanced osteoarthritis of the knee joint and correct the limb alignment and biomechanics to improve patients' quality of life. Apart from medio-lateral balancing, balancing flexion and extension gaps is a prerogative to achieve good results. This study proposes a novel surgical technique of postero-central slice osteotomy of the proximal tibia (PCSO-PT) for correcting tight extension gaps in posterior-stabilized (PS) knees and assesses its clinical and functional outcomes. METHODS A prospective study was conducted on 84 consecutive knees with tricompartmental osteoarthritis and varus deformity, requiring PCSO of the proximal tibia during PS TKA between January 2016 and July 2018. Knee Society scores, flexion deformity, range of motion, antero-posterior instability, and complications were assessed at regular intervals for a minimum of two years postoperatively. RESULTS Residual flexion deformities less than 11° after posterior capsular release were successfully corrected by the osteotomy. The mean preoperative flexion deformity of 18.1 ± 2.5° improved to 8.6 ± 2.2° intraoperatively after posterior capsular release from the femoral end and to 0.65 ± 0.76° intraoperatively immediately after the osteotomy, with no residual flexion deformity noted in any patient six weeks postoperatively. It had no negative effect on the significant post-TKA improvement of the mean Knee Society score from 32 ± 12 preoperatively to 94 ± 3 at the terminal follow-up. A direct correlation between preoperative flexion deformity and a resistant, tight extension gap (P = 0.003) was noted. There was no increase in coronal plane or sagittal plane instabilities in midflexion or on mobilization throughout the follow-up period, nor were any major adverse effects noted in this period. CONCLUSION A postero-central slice osteotomy of the proximal tibia is an effective and safe alternative to overcoming tight extension during TKA after femoral-end capsular release, instead of capsular release from the tibial end or midcapsular region.
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Affiliation(s)
- Amyn M Rajani
- Consultant Orthopaedic surgeon, Department of Orthopaedics, Address: OAKS Clinic, 707 Panchshil Plaza, N S Patkar Marg, opp. Ghanasingh Fine Jewels, next to Dharam Palace, Gamdevi, Mumbai, Maharashtra 400007.
| | - Anmol Rs Mittal
- Consultant Orthopaedic surgeon, Department of Orthopaedics, Address: OAKS Clinic, 707 Panchshil Plaza, N S Patkar Marg, opp. Ghanasingh Fine Jewels, next to Dharam Palace, Gamdevi, Mumbai, Maharashtra 400007
| | - Urvil A Shah
- Consultant Orthopaedic surgeon, Department of Orthopaedics, Address: OAKS Clinic, 707 Panchshil Plaza, N S Patkar Marg, opp. Ghanasingh Fine Jewels, next to Dharam Palace, Gamdevi, Mumbai, Maharashtra 400007
| | - Vishal U Kulkarni
- Clinical Associate, Department of Orthopaedics, Address: OAKS Clinic, 707 Panchshil Plaza, N S Patkar Marg, Gamdevi, Mumbai, Maharashtra 400007
| | - Rishab Dubey
- Clinical Associate, Department of Orthopaedics, Address: OAKS Clinic, 707 Panchshil Plaza, N S Patkar Marg, Gamdevi, Mumbai, Maharashtra 400007
| | - Alisha A Rajani
- Consultant Musculoskeletal radiologist, Department of Radiodiagnosis, Address: OAKS Clinic, 707 Panchshil Plaza, N S Patkar Marg, Gamdevi, Mumbai, Maharashtra 400007
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Andreassen TE, Hume DR, Hamilton LD, Higinbotham SE, Shelburne KB. Automated 2D and 3D finite element overclosure adjustment and mesh morphing using generalized regression neural networks. Med Eng Phys 2024; 126:104136. [PMID: 38621835 PMCID: PMC11064159 DOI: 10.1016/j.medengphy.2024.104136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 04/17/2024]
Abstract
Computer representations of three-dimensional (3D) geometries are crucial for simulating systems and processes in engineering and science. In medicine, and more specifically, biomechanics and orthopaedics, obtaining and using 3D geometries is critical to many workflows. However, while many tools exist to obtain 3D geometries of organic structures, little has been done to make them usable for their intended medical purposes. Furthermore, many of the proposed tools are proprietary, limiting their use. This work introduces two novel algorithms based on Generalized Regression Neural Networks (GRNN) and 4 processes to perform mesh morphing and overclosure adjustment. These algorithms were implemented, and test cases were used to validate them against existing algorithms to demonstrate improved performance. The resulting algorithms demonstrate improvements to existing techniques based on Radial Basis Function (RBF) networks by converting to GRNN-based implementations. Implementations in MATLAB of these algorithms and the source code are publicly available at the following locations: https://github.com/thor-andreassen/femors; https://simtk.org/projects/femors-rbf; https://www.mathworks.com/matlabcentral/fileexchange/120353-finite-element-morphing-overclosure-reduction-and-slicing.
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Affiliation(s)
- Thor E Andreassen
- Center for Orthopaedic Biomechanics, Mechanical and Materials Engineering, University of Denver, Denver, CO, USA.
| | - Donald R Hume
- Center for Orthopaedic Biomechanics, Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| | - Landon D Hamilton
- Center for Orthopaedic Biomechanics, Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| | - Sean E Higinbotham
- Center for Orthopaedic Biomechanics, Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| | - Kevin B Shelburne
- Center for Orthopaedic Biomechanics, Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
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Walker PS, Borukhov I, LiArno S. Obtaining anatomic motion and laxity characteristics in a total knee design. Knee 2022; 35:133-141. [PMID: 35313242 DOI: 10.1016/j.knee.2022.02.013] [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: 02/20/2021] [Revised: 01/03/2022] [Accepted: 02/25/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Since the introduction of the first total knee designs, a frequent design goal has been to reproduce normal knee motion. However, studies of many currently used total knee designs, have shown that this goal has not been achieved. We proposed that Guided Motion total knee designs, could achieve more anatomic motion than present standard designs. METHODS Several Guided Motion knees for application without cruciate ligaments were designed using a computer method where the bearing surfaces were generated by the motion required. A knee testing machine was constructed where physiological forces including compressive, shear and torque were applied during knee flexion. The neutral path of motion and the laxity about the neutral path were measured. This evaluation method was a modification of the ASTM standard Constraint Test. RESULTS The motions of the Guided Motion knees and a standard PS knee were compared with the anatomic motion of knee specimens determined in an earlier study The Guided Motion knees showed motion patterns which were closer to anatomic than the PS knee. CONCLUSIONS The results provided justification for carrying out further evaluations of functional conditions, using either knee simulators or computer modelling. If anatomic motions could be reproduced in vivo, it is possible that clinical outcomes could be improved.
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Affiliation(s)
- Peter S Walker
- NYU Langone Orthopedic Hospital, New York, NY, United States.
| | - Ilya Borukhov
- NYU Langone Orthopedic Hospital, New York, NY, United States.
| | - Sally LiArno
- NYU Langone Orthopedic Hospital, New York, NY, United States.
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Compartmental force and contact location sensing in instrumented total knee replacements. Med Eng Phys 2020; 83:64-72. [PMID: 32807349 DOI: 10.1016/j.medengphy.2020.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 04/04/2020] [Accepted: 07/18/2020] [Indexed: 11/20/2022]
Abstract
For the past three decades, total knee replacement has become the main solution for progressed knee injuries and diseases. Due to a lack of postoperative in vivo data, a universal correlation between intra- and postoperative soft tissue balance in the knee joint has not been established. In this work, an instrumented knee implant design with six piezoelectric transducers embedded in the tibial bearing is proposed. The aim of the presented device is to measure the total and compartmental forces as well as to track the location of contact points on the medial and lateral compartments of the bearing. A numerical analysis using finite element software is first performed to obtain the best sensory system arrangement inside the bearing. The chosen design is then used to fabricate a prototype of the device. Several experiments are designed and performed using the prototype, and the ability of the proposed system to track the location and magnitude of applied compartmental forces on the bearing is evaluated. The experimental results show that the instrumented knee bearing is able to accurately measure the compartmental force quantities with a maximum error of 2.6% of the peak axial load, and the contact point locations with a maximum error of less than 1 mm.
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Abstract
Flexion instability after total knee arthroplasty (TKA) is caused by an increased flexion gap compared with extension gap. Patients present with recurrent effusions, subjective instability (especially going downstairs), quadriceps weakness, and diffuse periretinacular pain. Manual testing for laxity in flexion is commonly done to confirm a diagnosis, although testing positions and laxity grades are inconsistent. Nonsurgical treatment includes quadriceps strengthening and bracing treatment. The mainstays to surgical management of femoral instability involve increasing the posterior condylar offset, decreasing the tibial slope, raising the joint line in combination with a thicker polyethylene insert, and ensuring appropriate rotation of implants. Patient outcomes after revision TKA for flexion instability show the least amount of improvement when compared with revisions for other TKA failure etiologies. Future work is needed to unify reproducible diagnostic criteria. Advancements in biomechanical analysis with motion detection, isokinetic quadriceps strength testing, and computational modeling are needed to advance the collective understanding of this underappreciated failure mechanism.
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Twiggs JG, Wakelin EA, Roe JP, Dickison DM, Fritsch BA, Miles BP, Ruys AJ. Patient-Specific Simulated Dynamics After Total Knee Arthroplasty Correlate With Patient-Reported Outcomes. J Arthroplasty 2018; 33:2843-2850. [PMID: 29807792 DOI: 10.1016/j.arth.2018.04.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/16/2018] [Accepted: 04/20/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Component alignment variation following total knee arthroplasty (TKA) does not fully explain the instance of long-term postoperative pain. Joint dynamics following TKA vary with component alignment and patient-specific musculoskeletal anatomy. Computational simulations allow joint dynamics outcomes to be studied across populations. This study aims to determine if simulated postoperative TKA joint dynamics correlate with patient-reported outcomes. METHODS Landmarking and 3D registration of implants was performed on 96 segmented postoperative computed tomography scans of TKAs. A cadaver rig-validated platform for generating patient-specific simulation of deep knee bend kinematics was run for each patient. Resultant dynamic outcomes were correlated with a 12-month postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS). A Classification and Regression Tree (CART) was used for determining nonlinear relationships. RESULTS Nonlinear relationships between the KOOS pain score and rollback and dynamic coronal alignment were found to be significant. Combining a dynamic coronal angular change from extension to full flexion between 0° and 4° varus (long leg axis) and measured rollback of no more than 6 mm without rollforward formed a "kinematic safe zone" of outcomes in which the postoperative KOOS score is 10.5 points higher (P = .013). CONCLUSION The study showed statistically significant correlations between kinematic factors in a simulation of postoperative TKA and postoperative KOOS scores. The presence of a dynamic safe zone in the data suggests a potential optimal target for any given individual patient's joint dynamics and the opportunity to preoperatively determine a patient-specific alignment target to achieve those joint dynamics.
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Affiliation(s)
- Joshua G Twiggs
- 360 Knee Systems, Sydney, Australia; Department of Biomedical Engineering, University of Sydney, Sydney, Australia
| | | | - Justin P Roe
- North Sydney Orthopaedic and Sports Medicine Centre, The Mater Hospital, North Sydney, Australia
| | | | | | | | - Andrew J Ruys
- Department of Biomedical Engineering, University of Sydney, Sydney, Australia
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Nielsen ES, Hsu A, Patil S, Colwell CW, D'Lima DD. Second-Generation Electronic Ligament Balancing for Knee Arthroplasty: A Cadaver Study. J Arthroplasty 2018; 33:2293-2300. [PMID: 29555494 DOI: 10.1016/j.arth.2018.02.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Knee instability is emerging as a major complication after total knee arthroplasty (TKA), with ligament laxity and component alignment listed as important contributory factors. Knee balancing remains an art and is largely dependent on the surgeon's subjective "feel." The objectives were to measure the accuracy of an electronic balancing device to document the magnitude of correction in knee balance after soft-tissue releases and measure change in knee laxity after medial release. METHODS The accuracy of a second-generation electronic ligament-balancing device was compared with that of 2 mechanical balancing instruments. TKA was performed in 12 cadaver knees. Soft-tissue balance was measured sequentially before TKA, after mounting a trial femoral component, after medial release, and after resecting the posterior cruciate ligament. Coronal laxity of the knee under a 10 Nm valgus moment was measured before and after medial release. RESULTS The electronic balancing instrument was more accurate than mechanical instruments in measuring distracted gap and distraction force. On average, before TKA, the flexion gap was wider than the extension gap, and the medial gap was tighter than the lateral gap. Medial release increased the medial gap in flexion and increased passive knee valgus laxity. Posterior cruciate ligament release increased the tibiofemoral gap in both flexion and extension with a greater increase in the lateral gap. CONCLUSION The second-generation electronic balancing device was significantly more accurate than mechanical instruments and could record knee balance over the entire range of flexion. More accurate soft-tissue balance may enhance outcomes after TKA.
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Affiliation(s)
- Evan S Nielsen
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Scripps Health, La Jolla, CA
| | - Albert Hsu
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Scripps Health, La Jolla, CA
| | - Shantanu Patil
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Scripps Health, La Jolla, CA
| | - Clifford W Colwell
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Scripps Health, La Jolla, CA
| | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Scripps Health, La Jolla, CA
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Halewood C, Athwal KK, Amis AA. Pre-clinical assessment of total knee replacement anterior-posterior constraint. J Biomech 2018; 73:153-160. [PMID: 29622481 DOI: 10.1016/j.jbiomech.2018.03.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 11/19/2022]
Abstract
Pre-clinical, bench-top assessment of Total Knee Replacements (TKR) can provide information about the inherent constraint provided by a TKR, which does not depend on the condition of the patient undergoing the arthroplasty. However little guidance is given by the ASTM standard on test configurations such as medial-lateral (M:L) loading distribution, flexion angle or restriction of secondary motions. Using a purpose built rig for a materials testing machine, four TKRs currently in widespread clinical use, including medial-pivot and symmetrical condyle types, were tested for anterior-posterior translational constraint. Compressive joint loads from 710 to 2000 N, and a range of medial-lateral (M:L) load distributions, from 70:30% to 30:70% M:L, were applied at different flexion angles with secondary motions unconstrained. It was found that TKA constraint was significantly less at 60 and 90° flexion than at 0°, whilst increasing the compressive joint load increased the force required to translate the tibia to limits of AP constraint at all flexion angles tested. Additionally when M:L load distribution was shifted medially, a coupled internal rotation was observed with anterior translation and external rotation with posterior translation. This paper includes some recommendations for future development of pre-clinical testing methods.
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Affiliation(s)
- C Halewood
- Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - K K Athwal
- Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK.
| | - A A Amis
- Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London School of Medicine, Charing Cross Hospital, London W6 8RF, UK
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