The Influence of Knee Phenotypes Based on Coronal Plane Alignment of the Knee on Intraoperative Soft Tissue Balance and Clinical Outcomes: Comparison between Kinematically and Mechanically Aligned Total Knee Arthroplasty

Shotaro Tachibana; Tomoyuki Matsumoto; Naoki Nakano; Masanori Tsubosaka; Tomoyuki Kamenaga; Yuichi Kuroda; Shinya Hayashi; Ryosuke Kuroda

doi:10.1055/a-2542-2583

The Journal of Knee Surgery, Table of Contents

J Knee Surg 2025; 38(09): 440-447
DOI: 10.1055/a-2542-2583

Original Article

The Influence of Knee Phenotypes Based on Coronal Plane Alignment of the Knee on Intraoperative Soft Tissue Balance and Clinical Outcomes: Comparison between Kinematically and Mechanically Aligned Total Knee Arthroplasty

Shotaro Tachibana

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

,

Tomoyuki Matsumoto

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

,

Naoki Nakano

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

,

Masanori Tsubosaka

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

,

Tomoyuki Kamenaga

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

,

Yuichi Kuroda

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

,

Shinya Hayashi

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

,

Ryosuke Kuroda

¹Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan

› Author Affiliations

Abstract

This study examined the impact of preoperative coronal plane alignment of the knee (CPAK) classification on intraoperative soft tissue balance and postoperative clinical outcomes in patients undergoing modified kinematically aligned (mKA) and mechanically aligned (MA) total knee arthroplasty (TKA). A total of 90 knees treated with mKA-TKA and 63 knees treated with MA-TKA were classified based on CPAK. After adjusting for confounding factors, intraoperative soft tissue balance, including varus/valgus balance and joint component gap, range of motion (ROM), and the 2011 Knee Society score (KSS), were compared 1 year postoperatively using one-way ANOVA. The analysis included 69 knees classified as type I and 18 type II in the mKA group, and 52 type I and 11 type II in the MA group. Varus balance at 30 and 60 degrees flexion was significantly larger in mKA type I and MA type I compared to mKA type II (p < 0.001, 0.005, <0.001, 0.008). At 90 degrees, mKA type I showed a larger varus balance than both MA type I and mKA type II (p = 0.008, 0.002), while at 120 degrees, mKA type I demonstrated a larger varus balance than MA type I (p < 0.001). The improved ROM in mKA type I was greater than in MA type I (p = 0.04). Improvement in the objective indicator of the 2011 KSS was better in mKA type I than in mKA type II, and patient satisfaction was significantly better in mKA type I compared to both mKA type II and MA type I (p = 0.01, <0.001, 0.03). mKA type I preserved lateral laxity in mid- and deep flexion compared to both mKA type II and MA type I, potentially contributing to improved ROM and clinical outcomes.

Keywords

coronal plane alignment of the knee - total knee arthroplasty - kinematic alignment - mechanical alignment

Full Text

References

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 Mannion AF, Kämpfen S, Munzinger U, Kramers-de Quervain I. The role of patient expectations in predicting outcome after total knee arthroplasty. Arthritis Res Ther 2009; 11 (05) R139
4 Kim DK, Seo MC, Song SJ, Kim KI. Are Korean patients different from other ethnic groups in total knee arthroplasty?. Knee Surg Relat Res 2015; 27 (04) 199-206
5 Ensini A, Catani F, Leardini A, Romagnoli M, Giannini S. Alignments and clinical results in conventional and navigated total knee arthroplasty. Clin Orthop Relat Res 2007; 457 (457) 156-162
6 Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?. Clin Orthop Relat Res 2010; 468 (01) 57-63
7 Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. National Joint Registry for England and Wales, Data from the National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. J Bone Joint Surg Br 2007; 89 (07) 893-900
8 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
9 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
10 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
11 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
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 (07) 907-913
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 MacDessi SJ, Griffiths-Jones W, Harris IA, Bellemans J, Chen DB. Coronal plane alignment of the knee (CPAK) classification. Bone Joint J 2021; 103-B (02) 329-337
15 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 (05) 640-646
16 Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res 2011; 46 (03) 399-424
17 Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med 2009; 28 (25) 3083-3107
18 Austin PC, Stuart EA. The performance of inverse probability of treatment weighting and full matching on the propensity score in the presence of model misspecification when estimating the effect of treatment on survival outcomes. Stat Methods Med Res 2017; 26 (04) 1654-1670
19 Matsumoto T, Takayama K, Ishida K. et al. Intraoperative soft tissue balance/kinematics and clinical evaluation of modified kinematically versus mechanically aligned total knee arthroplasty. J Knee Surg 2020; 33 (08) 777-784
20 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
21 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
22 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
23 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
24 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
25 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
26 Muratsu H, Matsumoto T, Kubo S. et al. Femoral component placement changes soft tissue balance in posterior-stabilized total knee arthroplasty. Clin Biomech (Bristol) 2010; 25 (09) 926-930
27 Koh IJ, Lin CC, Patel NA. et al. Kinematically aligned total knee arthroplasty reproduces more native rollback and laxity than mechanically aligned total knee arthroplasty: a matched pair cadaveric study. Orthop Traumatol Surg Res 2019; 105 (04) 605-611
28 Gao ZX, Long NJ, Zhang SY, Yu W, Dai YX, Xiao C. Comparison of kinematic alignment and mechanical alignment in total knee arthroplasty: a meta-analysis of randomized controlled clinical trials. Orthop Surg 2020; 12 (06) 1567-1578
29 Li Y, Wang S, Wang Y, Yang M. Does kinematic alignment improve short-term functional outcomes after total knee arthroplasty compared with mechanical alignment? A systematic review and meta-analysis. J Knee Surg 2018; 31 (01) 78-86
30 Niki Y, Nagura T, Kobayashi S, Udagawa K, Harato K. Who will benefit from kinematically aligned total knee arthroplasty? perspectives on patient-reported outcome measures. J Arthroplasty 2020; 35 (02) 438-442.e2
31 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
32 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
33 Tamaki M, Ishibashi T, Yamazaki T. et al. Maximum flexion and lateral rollback revealed better patient satisfaction after total knee arthroplasty. Knee Surg Relat Res 2024; 36 (01) 12
34 Purudappa PP, Sharma OP, Chandrasekharan J, Sudevan PJ, Mounasamy V, Sambandam SN. Clinical outcome, functional outcome and patient satisfaction after cruciate retaining total knee arthroplasty for stiff arthritic knee - a short term outcome study. J Orthop 2019; 20: 6-11