Contribution of the Medial Iliofemoral Ligament to Hip Stability After Total Hip Arthroplasty Through the Direct Anterior Approach

BACKGROUND

Dislocation after total hip arthroplasty (THA) is a primary reason for THA revision. During THA through the direct anterior approach (DAA), the iliofemoral ligament, which provides the main resistance to external rotation (ER) of the hip, is commonly partially transected. We asked: (1) what is the contribution of the medial iliofemoral ligament to resisting ER after DAA THA? and (2) how much resistance to ER can be restored by repairing the ligament?

METHODS

A fellowship-trained surgeon performed DAA THA on 9 cadaveric specimens. The specimens were computed tomography scanned before and after implantation. Prior to testing, the ER range of motion of each specimen to impingement in neutral and 10° of extension was computationally predicted. Each specimen was tested on a 6-degrees-of-freedom robotic manipulator. The pelvis was placed in neutral and 10° of extension. The femur was externally rotated until it reached the specimen's impingement target. Total ER torque was recorded with the medial iliofemoral ligament intact, after transecting the ligament, and after repair. Torque at extremes of motion was calculated for each condition. To isolate the contribution of the native ligament, the torque for the transected state was subtracted from both the native and repaired conditions.

RESULTS

The medial iliofemoral ligament contributed an average of 68% (range, 34 to 87) of the total torque at the extreme of motion in neutral and 80% (58 to 97) in 10⁰ of extension. The repaired ligament contributed 17% (1 to 54) of the total torque at the extreme of motion in neutral and 14% (5 to 38) in 10⁰ of extension, restoring on average 18 to 25% of the native resistance against ER.

CONCLUSIONS

The medial iliofemoral ligament was an important contributor to the hip torque at the extreme of motion during ER. Repairing the ligament restored a fraction of its ability to generate torque to resist ER.

Comparative Drug Solubility Studies Using Shake-Flask Versus a Laser-Based Robotic Method

Drug solubility is of central importance to the pharmaceutical sciences, but reported values often show discrepancies. Various factors have been discussed in the literature to account for such differences, but the influence of manual testing in comparison to a robotic system has not been studied adequately before. In this study, four expert researchers were asked to measure the solubility of four drugs with various solubility behaviors (i.e., paracetamol, mesalazine, lamotrigine, and ketoconazole) in the same laboratory with the same instruments, method, and material sources and repeated their measurements after a time interval. In addition, the same solubility data were determined using an automated laser-based setup. The results suggest that manual testing leads to a handling influence on measured solubility values, and the results were discussed in more detail as compared to the automated laser-based system. Within the framework of unavoidable uncertainties of solubility testing, it is a possibility to combine minimal experimental testing that is preferably automated with mathematical modeling. That is a practical suggestion to support future pharmaceutical development in a more efficient way.

Femoral and tibial insert downsizing increases the laxity envelope in TKA

PURPOSE

This study examines the effect of component downsizing in a modern total knee arthroplasty (TKA) system on the laxity envelope of the knee throughout flexion.

METHODS

A robotic testing system was utilized to measure laxity envelopes in the implanted knee by in the anterior-posterior (AP), medial-lateral (ML), internal-external (IE) and varus-valgus (VV) directions. Five fresh-frozen cadavers were tested with a modern cruciate retaining TKA implantation, a 1-mm thinner polyethylene insert and a femoral component 2 mm smaller in the AP dimension.

RESULTS

The downsized tibial insert was more lax throughout the flexion arc with up to 2.0 mm more laxity in the AP direction at full extension, a 43.8% increase over the original implantation. A thinner insert consistently increased laxity throughout the arc of flexion in all degrees of freedom. Downsizing the femoral component resulted in 8.5 mm increase in AP laxity at 90°, a 73.9% increase. In mid-flexion, downsizing the femur produced similar laxity values to the downsized insert in AP, ML, IE and VV directions.

CONCLUSION

Downsizing the TKA components had significant effects on laxity throughout flexion. Downsizing a femoral component 2 mm had an equivalent increase in laxity in mid-flexion as downsizing the tibial insert 1 mm. This study quantifies the importance of choosing the appropriate implant component size, having the appropriate size available and the effect of downsizing. The laxity of the implanted knee contributes to how the implant feels to the patient and ultimately the patient's satisfaction with their new knee.

Biomechanical comparison of single-tunnel-double-bundle and single-bundle anterior cruciate ligament reconstructions

BACKGROUND

Anatomic double-bundle reconstruction has been thought to better simulate the anterior cruciate ligament anatomy. It is, however, a technically challenging procedure, associated with longer operation time and higher cost.

HYPOTHESIS

Double-bundle anterior cruciate ligament reconstruction using a single femoral and tibial tunnel can closely reproduce intact knee kinematics.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen human cadaveric knee specimens were tested using a robotic testing system to investigate the kinematic response of the knee joint under an anterior tibial load (130 N), simulated quadriceps load (400 N), and combined torques (5 N.m valgus and 5 N.m internal tibial torques) at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion. Each knee was tested sequentially under 4 conditions: (1) anterior cruciate ligament intact, (2) anterior cruciate ligament deficient, (3) single-bundle anterior cruciate ligament reconstruction using quadrupled hamstring tendon, and (4) single-tunnel-double-bundle anterior cruciate ligament reconstruction using the same tunnels and quadrupled hamstring tendon graft as in the single-bundle anterior cruciate ligament reconstruction.

RESULTS

Single-tunnel-double-bundle anterior cruciate ligament reconstruction more closely restored the intact knee kinematics than single-bundle anterior cruciate ligament reconstruction at low flexion angles (< or =30 degrees ) under the anterior tibial load and simulated muscle load (P < .05). However, single-tunnel-double-bundle anterior cruciate ligament reconstruction overconstrained the knee joint at high flexion angles (> or =60 degrees ) under the anterior tibial load and at 0 degrees and 30 degrees of flexion under combined torques.

CONCLUSION

This double-bundle anterior cruciate ligament reconstruction using a single tunnel can better restore anterior tibial translations to the intact level compared with single-bundle anterior cruciate ligament reconstruction at low flexion angles, but it overconstrained the knee joint at high flexion angles.

CLINICAL RELEVANCE

This technique could be an alternative for both single-bundle and double-tunnel-double-bundle anterior cruciate ligament reconstructions to reproduce intact knee kinematics and native anterior cruciate ligament anatomy.