Intraoperative Soft Tissue Balance/Kinematics and Clinical Evaluation of Modified Kinematically versus Mechanically Aligned Total Knee Arthroplasty

Abstract

Recently, kinematically aligned total knee arthroplasty has been found to achieve better clinical outcomes than mechanically aligned TKA. Despite the good clinical outcomes that are reported at short- to mid-term follow-up, intraoperative variables that are associated with a better outcome have not been measured. Therefore, this study was conducted to compare intraoperative kinematics/soft tissue balance and the clinical outcomes of patients who underwent modified kinematically (restricted tibial cut) or mechanically aligned total knee arthroplasty. Sixty cruciate-retaining total knee arthroplasties (30 modified kinematically [3-degree varus and 7-degree posterior slope in tibial cut] and 30 mechanically aligned) were performed in patients with varus-type osteoarthritis using a navigation system. Intraoperative kinematics assessed by the navigation system and soft tissue balance assessed by an offset-type tensor were compared between the groups. One year postoperatively, the range of motion and 2011 Knee Society scores were compared between the groups. Kinematic assessment exhibited that tibial internal rotation during flexion was significantly maintained in the kinematic compared with the mechanical group (p < 0.05). Varus/valgus ligament balance at 90 and 120 degrees of flexion significantly maintained lateral laxity in the kinematic compared with the mechanical group (p < 0.05). Improvement of flexion angles, functional activity scores, and patient satisfaction were significantly better in the kinematic than in the mechanical group (p < 0.05). Modified kinematically aligned cruciate-retaining total knee arthroplasty maintained more tibial internal rotation and lateral laxity during flexion than mechanically aligned total knee arthroplasty; thus, the former may result in better clinical outcomes.

Keywords

total knee arthroplasty - kinematic alignment - mechanical alignment - soft tissue balance - kinematics

• References

• 1 Fehring TK, Odum S, Griffin WL, Mason JB, Nadaud M. Early failures in total knee arthroplasty. Clin Orthop Relat Res 2001; (392) 315-318
• 2 Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am 2011; 93 (17) 1588-1596
• 3 Leopold SS. Editor's spotlight/take 5: the Chitranjan S. Ranawat Award: no difference in 2-year functional outcomes using kinematic versus mechanical alignment in TKA: a randomized controlled clinical trial. Clin Orthop Relat Res 2017; 475 (01) 4-8
• 4 Schiraldi M, Bonzanini G, Chirillo D, de Tullio V. Mechanical and kinematic alignment in total knee arthroplasty. Ann Transl Med 2016; 4 (07) 130
• 5 Howell SM, Papadopoulos S, Kuznik KT, Hull ML. Accurate alignment and high function after kinematically aligned TKA performed with generic instruments. Knee Surg Sports Traumatol Arthrosc 2013; 21 (10) 2271-2280
• 6 Nedopil AJ, Singh AK, Howell SM, Hull ML. Does calipered kinematically aligned TKA restore native left to right symmetry of the lower limb and improve function?. J Arthroplasty 2018; 33 (02) 398-406
• 7 Courtney PM, Lee GC. Early outcomes of kinematic alignment in primary total knee arthroplasty: a meta-analysis of the literature. J Arthroplasty 2017; 32 (06) 2028-2032.e1
• 8 Yoon JR, Han SB, Jee MK, Shin YS. Comparison of kinematic and mechanical alignment techniques in primary total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2017; 96 (39) e8157
• 9 Lee YS, Howell SM, Won YY. , et al. Kinematic alignment is a possible alternative to mechanical alignment in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25 (11) 3467-3479
• 10 Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 2012; 470 (01) 45-53
• 11 Vanlommel L, Vanlommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 2013; 21 (10) 2325-2330
• 12 Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematically and mechanically aligned total knee replacements: two-year clinical results. Bone Joint J 2014; 96-B [phone]
• 13 Dossett HG, Swartz GJ, Estrada NA, LeFevre GW, Kwasman BG. Kinematically versus mechanically aligned total knee arthroplasty. Orthopedics 2012; 35 (02) e160-e169
• 14 Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML. Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category?. Clin Orthop Relat Res 2013; 471 (03) 1000-1007
• 15 Howell SM, Papadopoulos S, Kuznik K, Ghaly LR, Hull ML. Does varus alignment adversely affect implant survival and function six years after kinematically aligned total knee arthroplasty?. Int Orthop 2015; 39 (11) 2117-2124
• 16 Ishikawa M, Kuriyama S, Ito H, Furu M, Nakamura S, Matsuda S. Kinematic alignment produces near-normal knee motion but increases contact stress after total knee arthroplasty: a case study on a single implant design. Knee 2015; 22 (03) 206-212
• 17 Nakamura S, Tian Y, Tanaka Y. , et al. The effects of kinematically aligned total knee arthroplasty on stress at the medial tibia: a case study for varus knee. Bone Joint Res 2017; 6 (01) 43-51
• 18 Tanaka Y, Nakamura S, Kuriyama S. , et al. Medial tilting of the joint line in posterior stabilized total knee arthroplasty increases contact force and stress. Clin Biomech (Bristol, Avon) 2018; 53: 54-59
• 19 Shelton TJ, Nedopil AJ, Howell SM, Hull ML. Do varus or valgus outliers have higher forces in the medial or lateral compartments than those which are in-range after a kinematically aligned total knee arthroplasty? limb and joint line alignment after kinematically aligned total knee arthroplasty. Bone Joint J 2017; 99-B (10) 1319-1328
• 20 Matsumoto T, Kuroda R, Kubo S, Muratsu H, Mizuno K, Kurosaka M. The intra-operative joint gap in cruciate-retaining compared with posterior-stabilised total knee replacement. J Bone Joint Surg Br 2009; 91 (04) 475-480
• 21 Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new Knee Society knee scoring system. Clin Orthop Relat Res 2012; 470 (01) 3-19
• 22 Jenny JY, Boeri C, Picard F, Leitner F. Reproducibility of intra-operative measurement of the mechanical axes of the lower limb during total knee replacement with a non-image-based navigation system. Comput Aided Surg 2004; 9 (04) 161-165
• 23 Matsumoto T, Hashimura M, Takayama K. , et al. A radiographic analysis of alignment of the lower extremities--initiation and progression of varus-type knee osteoarthritis. Osteoarthritis Cartilage 2015; 23 (02) 217-223
• 24 Matsumoto T, Takayama K, Muratsu H, Matsushita T, Kuroda R, Kurosaka M. Semimembranosus release reduces tibial internal rotation and flexion angle in cruciate-retaining total knee arthroplasty. J Arthroplasty 2015; 30 (09) 1537-1541
• 25 Akagi M, Mori S, Nishimura S, Nishimura A, Asano T, Hamanishi C. Variability of extraarticular tibial rotation references for total knee arthroplasty. Clin Orthop Relat Res 2005; (436) 172-176
• 26 Matsumoto T, Muratsu H, Kawakami Y. , et al. Soft-tissue balancing in total knee arthroplasty: cruciate-retaining versus posterior-stabilised, and measured-resection versus gap technique. Int Orthop 2014; 38 (03) 531-537
• 27 Matsumoto T, Muratsu H, Tsumura N. , et al. Joint gap kinematics in posterior-stabilized total knee arthroplasty measured by a new tensor with the navigation system. J Biomech Eng 2006; 128 (06) 867-871
• 28 Muratsu H, Matsumoto T, Kubo S. , et al. Femoral component placement changes soft tissue balance in posterior-stabilized total knee arthroplasty. Clin Biomech (Bristol, Avon) 2010; 25 (09) 926-930
• 29 Matsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R. Intraoperative soft tissue balance reflects minimum 5-year midterm outcomes in cruciate-retaining and posterior-stabilized total knee arthroplasty. J Arthroplasty 2012; 27 (09) 1723-1730
• 30 Yue B, Varadarajan KM, Rubash HE, Li G. In vivo function of posterior cruciate ligament before and after posterior cruciate ligament-retaining total knee arthroplasty. Int Orthop 2012; 36 (07) 1387-1392
• 31 Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39 (02) 175-191
• 32 Matsumoto T, Takayama K, Ishida K, Hayashi S, Hashimoto S, Kuroda R. Radiological and clinical comparison of kinematically versus mechanically aligned total knee arthroplasty. Bone Joint J 2017; 99-B [phone]
• 33 Nakano N, Matsumoto T, Muratsu H, Takayama K, Kuroda R, Kurosaka M. Postoperative knee flexion angle is affected by lateral laxity in cruciate-retaining total knee arthroplasty. J Arthroplasty 2016; 31 (02) 401-405
• 34 Kobayashi T, Suzuki M, Sasho T, Nakagawa K, Tsuneizumi Y, Takahashi K. Lateral laxity in flexion increases the postoperative flexion angle in cruciate-retaining total knee arthroplasty. J Arthroplasty 2012; 27 (02) 260-265
• 35 Matsuzaki T, Matsumoto T, Kubo S. , et al. Tibial internal rotation is affected by lateral laxity in cruciate-retaining total knee arthroplasty: an intraoperative kinematic study using a navigation system and offset-type tensor. Knee Surg Sports Traumatol Arthrosc 2014; 22 (03) 615-620
• 36 Matsuzaki T, Matsumoto T, Muratsu H. , et al. Kinematic factors affecting postoperative knee flexion after cruciate-retaining total knee arthroplasty. Int Orthop 2013; 37 (05) 803-808
• 37 Dennis DA, Komistek RD, Hoff WA, Gabriel SM. In vivo knee kinematics derived using an inverse perspective technique. Clin Orthop Relat Res 1996; (331) 107-117
• 38 Kanekasu K, Banks SA, Honjo S, Nakata O, Kato H. Fluoroscopic analysis of knee arthroplasty kinematics during deep flexion kneeling. J Arthroplasty 2004; 19 (08) 998-1003
• 39 Nakamura E, Banks SA, Tanaka A, Sei A, Mizuta H. Three-dimensional tibiofemoral kinematics during deep flexion kneeling in a mobile-bearing total knee arthroplasty. J Arthroplasty 2009; 24 (07) 1120-1124
• 40 Nakamura S, Takagi H, Asano T, Nakagawa Y, Kobayashi M, Nakamura T. Fluoroscopic and computed tomographic analysis of knee kinematics during very deep flexion after total knee arthroplasty. J Arthroplasty 2010; 25 (03) 486-491
• 41 Nakamura S, Sharma A, Kobayashi M. , et al. 3D in vivo femoro-tibial kinematics of tri-condylar total knee arthroplasty during kneeling activities. Knee 2014; 21 (01) 162-167