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21. Lutzner J, Firmbach FP, Lutzner C, Dexel J, Kirschner S.Similar stability and range of motion
between cruciate-retaining and cruciate-substituting ultracongruent insert total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015;23(6):1638–43.
22. Cavanaugh JT, Powers M.ACL rehabilitation progression: where are we now? Curr Rev
Musculoskelet Med. 2017;10(3):289–96.
23. Kono K, Inui H, Tomita T, etal. Bicruciate-stabilised total knee arthroplasty provides good
functional stability during high-exion weight-bearing activities. Knee Surg Sports Traumatol
Arthrosc. 2019;27(7):2096–103.
24. Hodgeson SM, Soeno T, Mears SC, Stambough JB, Barnes CL, Stronach BM.The medial
pivot design in total knee arthroplasty. Orthop Clin North Am. 2024;55(1):49–59.
25. Warth LC, Ishmael MK, Deckard ER, Ziemba-Davis M, Meneghini RM.Do medial pivot kinematics correlate with patient-reported outcomes after total knee arthroplasty? J Arthroplast.
2017;32(8):2411–6.
L. Sacco et al.
Part VI
Results
Chapter 15
Comparisons ofAll Designs withRespect
totheCruciate Ligaments
DouglasA.Dennis, JasonA.Bryman, andRichardD.Komistek
Introduction
Kinematic analysis of the knee is the study of motion patterns to assess interaction
of the femur relative to the tibia in healthy, nonimplanted knees and various prosthetic knee replacement designs. Numerous surgical techniques and total knee
arthroplasty (TKA) designs have been developed to achieve a well-balanced, functional TKA [1]. A comprehensive understanding of the geometric and kinematic
proles of these prostheses is vital for both arthroplasty surgeons and biomedical
engineers designing implants. Ideally, the motion patterns of a knee following TKA
should closely mimic those of the healthy, nonimplanted knee [2, 3]. Prior to exploring the kinematics of specic TKA implants, one must understand the methods of
TKA kinematic analysis, kinematics of the healthy, nonimplanted knee, and the
effects of sacricing the ACL in both healthy, nonimplanted knees and TKAs.
Early investigation of knee kinematics occurred primarily through invitro cadaveric studies and invivo gait laboratory analyses [4–6]. Both techniques have signicant drawbacks [7–12]. In cadaveric studies, mechanical actuators intended to
D. A. Dennis (*)
Colorado Joint Replacement, AdventHealth Porter, Denver, CO, USA
Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
Department of Biomedical Engineering, University of Denver, Denver, CO, USA
Department of Orthopaedics, University of Colorado Health School of Medicine,
Aurora, CO, USA
e-mail: roseannjohnson@adventhealth.com
J. A. Bryman
Colorado Joint Replacement, AdventHealth Porter, Denver, CO, USA
R. D. Komistek
Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
Switzerland AG 2024
A. J. Tria Jr., G. R. Scuderi (eds.), The Cruciate Ligaments in Total Knee
Arthroplasty, https://doi.org/10.1007/978-3-031-75992-5_15
185© The Author(s), under exclusive license to Springer Nature
186
D. A. Dennis et al.
simulate muscle activity often do not duplicate invivo motion and the ligament
properties change, leading to incorrect tensile constraints. Furthermore, the marker
systems used in the analysis of gait laboratory systems are imperfect and cannot be
corrected even with more markers. Soft tissue artifact and the movement of these
markers relative to the bone result in out of plane rotational and translational errors
[13, 14]. Building on some of the weaknesses of the now historical cadaveric and
gait lab analyses, in vivo video uoroscopic techniques have emerged as a popular
method of kinematic evaluation. Video uoroscopy uses sequential radiographic
images to create a real-time video of dynamic activities, allowing for twodimensional visualization of the knee joint throughout an entire activity [15, 16]
(Fig.15.1). This offers the distinct advantage of motion analysis of patients under
invivo, weightbearing, dynamic conditions.
The use of weightbearing, video uoroscopic analysis, which has remained the
gold-standard of kinematic analysis since its introduction in the 1990s, has demonstrated numerous abnormal kinematic patterns exist following TKA when compared
to the kinematic motion patterns of healthy, nonimplanted knees with intact cruciate
ligaments [17–25]. Specically, abnormal kinematic patterns identied following
TKA include paradoxical anteroposterior (AP) femorotibial translation, reverse
axial rotation (AR), femoral condylar liftoff (FCLO), and reduced weightbearing
knee range of motion (ROM; Tables 15.1, 15.2, and 15.3). AP femorotibial translation describes the sagittal plane movement of the femoral condyle contact points on
the tibial plateau during any weightbearing motion activity. The primary activities
most commonly analyzed have included gait, weightbearing deep knee bends
(WB-DKB), and a step-up maneuver. Axial rotation assesses the rotation of the
femur with respect to the tibia throughout range of motion. Lastly, FCLO is dened
as separation of the femoral and tibial condylar surfaces during weightbearing
activities.
Fig. 15.1 Fluoroscopic images of a patient with a PCR TKA performing a WB-DKB maneuver to
maximum weightbearing exion, in 30-degree increments. Also shown is the corresponding threedimensional CAD model registered to the two-dimensional uoroscopic image extracting threedimensional invivo kinematics
15 Comparisons ofAll Designs withRespect totheCruciate Ligaments
187
Table 15.1 Summary of anterior-posterior translation during the stance phase of gait in implanted
and nonimplanted knees
Weightbearing gait
Posterior
Knee
type
# of
knees
rollback
(HS-TO)
Lateral
(%)
Medial
(%)
Average (±SD)
movement (HS-TO)
Lateral
(mm)
Medial
(mm)
Anterior slide
>3.0mm
Any
a
increment,
any
condyle
(%)
HS-TO,
any
condyle
(%)
Max
movement
HS-TO,
any
condyle
b
(mm)
c
Normal 10 90 50 −5.8±8.1 −0.4±6.6 30 90 11.9
ACLD 5 60 60 −1.9±4.4 −2.3±6.8 20 40 3.0
PCRF 83 61 46 −1.2±3.2 0.0±2.3 22 52 6.7
PSF 74 61 55 −1.3±3.2 0.5±3.3 23 50 8.1
BCRF 15 53 73 −3.7±7.4 −1.6±7.7 13 40 18.2
PCRM 10 50 40 0.2±5.7 −0.3±4.5 20 50 20.9
PCSM 35 46 46 0.3±2.4 −0.2±3.1 26 51 6.9
PSM 44 52 34 −0.7±2.7 0.5±2.2 11 25 5.4
All
261 57 48 −1.0±3.5 0.2±3.3 19 46 20.9
TKAs
MED
68 __ 59 __ −0.3±2.7 10 26 7.7
UKA
LAT
7 43 __ 1.3±3.9 __ 33 17 8.8
UKA
Note: This cumulative data originates from many peer-reviewed, published articles from the senior
authors. Within the individual papers, all subjects chosen for analysis were considered clinically
excellent with knee scores >90 point and without measurable instability or functional disability
related to pain
Adapted from Angerame etal. [26]; Published in part: Dennis D et al. [27]; Published in full:
Mueller etal. [28]
HS-TO Heel Strike to toe off, ACLD Anterior cruciate ligament-decient knee, PCRF Posterior
cruciate-retaining TKA, xed bearing, PSF Posterior stabilized TKA, xed bearing, BCRF
Bicruciate retaining TKA, xed bearing, PCRM Posterior cruciate-retaining TKA, mobile bearing,
PSM Posterior stabilized TKA, mobile bearing, BCSF Bicruciate stabilized TKA, xed bearing,
MED UKA medial unicompartmental knee arthroplasty, LAT UKA lateral unicompartmental knee
arthroplasty
a
Refers to the percentage of knees demonstrating anterior slide of either condyle only comparing
the increment of heel strike vs. the increment of toe off
b
Refers to the percentage of knees demonstrating anterior slide of either condyle during any two
increments of stance phase (i.e., heel strike vs. 33% of stance phase)
c
Represents the maximum amount of AP translation (anterior-most contact position vs. the most
posterior contact position) observed within each knee type analyzed from heel strike to toe off
188
Table 15.2 Summary of anterior-posterior translation during a weightbearing, deep knee bend in
implanted and nonimplanted knees
Weightbearing, deep knee bend
Posterior rollback
(0–90°)
Knee
type
Normal 104 100 98 −16.4±6.8 −8.9±6.0 2 15
ACLD 5 100 100 −13.3±8.3 −5.9±1.9 0 20
PCRF 43 68 34 −2.4±4.2 0.6±3.7 24 52
PSF 457 71 61 −8.5±8.4 −4.0±5.4 4 27
BCRF 34 91 83 −10.4±5.0 −5.6±5.1 6 32
PCRM 107 68 46 −1.3±3.5 0.4±3.8 25 60
PCSM 76 85 37 −2.1±2.7 0.4±2.6 18 54
PSM 341 59 26 −2.7±4.2 0.6±3.7 16 27
BCSF 95 100 100 −21.9±5.9 −12.5±3.1 0 7
All
TKAs
MED
UKA
LAT
UKA
Note: This cumulative data originates from many peer-reviewed, published articles from the senior
authors. Within the individual papers, all subjects chose for the analyses were considered clinically
excellent with knee scores >90 points and without measurable instability or functional disability
related to pain
Adapted from Angerame etal. [26]; Published in part: Dennis D et al. [27]; Published in full:
Mueller etal. [28]
HS-TO Heel Strike to toe off, ACLD Anterior cruciate ligament-decient knee, PCRF Posterior
cruciate-retaining TKA, xed bearing, PSF Posterior stabilized TKA, xed bearing, BCRF
Bicruciate retaining TKA, xed bearing, PCRM Posterior cruciate-retaining TKA, mobile bearing,
PSM Posterior stabilized TKA, mobile bearing, BCSF Bicruciate stabilized TKA, xed bearing,
MED UKA Medial unicompartmental knee arthroplasty, LAT UKA lateral unicompartmental knee
arthroplasty
# of
Lateral
knees
(%)
1453 70 46 −5.8±5.9 −1.9±4.0 14 35
65 __ 63 __ −4.4±4.8 5 31
3 100 __ −6.3±7.6 __ 0 33
Medial
(%) Lateral (mm)
Average (±SD) movement
(0–90°) Anterior slide >3.0mm
Any
condyle
Medial
(mm)
(0–90°)
(%)
D. A. Dennis et al.
Any increment,
any condyle (%)
15 Comparisons ofAll Designs withRespect totheCruciate Ligaments
Table 15.3 Summary of axial rotation for implanted and nonimplanted knees during a
weightbearing deep knee bend
Average
Knee
type
Normal 17.8 31.6 −7.3
ACLD 9.8 21.2 −9.8
PCRF
TKA
PSF TKA 5.0 19.1 −18.1
BCRF
TKA
PCRM
TKA
PCSM
TKA
PSM
TKA
BCSF
TKA
All TKAs 4.8 27.1 −19.0
MED
UKA
LAT
UKA
Note: This cumulative data originates from many peer-reviewed, published articles from the senior
authors. Within individual papers, all subjects chosen for analyses were considered clinically
excellent with knee scores >90 point and without measurable instability or functional disability
related to pain
Adapted from Angerame etal. [26]; Published in part: Dennis D et al. [29]; Published in full:
Mueller etal. [28]
ACLD Anterior cruciate ligament-decient knee, PCRF Posterior cruciate-retaining TKA, xed
bearing, PSF Posterior stabilized TKA, xed bearing, BCRF Bicruciate retaining TKA, xed bearing, PCRM Posterior cruciate-retaining TKA, mobile bearing, PSM Posterior stabilized TKA,
mobile bearing, BCSF Bicruciate stabilized TKA, xed bearing, MED UKA medial unicompartmental knee arthroplasty, LAT UKA lateral unicompartmental knee arthroplasty
rotation
(0°–90°)
3.9 21.3 −19.0
5.6 20.9 −14.1
3.9 15.6 −11.4
3.3 11.4 −5.9
4.4 27.1 −14.9
10.7 22.5 −4.2
4.3 17.1 −15.3
−0.7 13.3 −16.1
Average maximum normal
rotation, any increment
(degrees)
Average maximum reverse
rotation, any increment
(degrees)
189
Healthy, Nonimplanted Knee Kinematics
AP Translation
Knee Society scores following TKA correlate with patients’ perception of increased
ROM [30]. Therefore, the AP translation of the femorotibial articulation is paramount in TKA design [31]. In a video uoroscopic analysis of ten healthy, nonimplanted knees, Dennis etal. assessed the movement of the tibiofemoral contact point
throughout the gait cycle [28]. During the stance phase of gait, all except one patient
experienced a motion pattern where the lateral condyle moved in the posterior
190
Medial
AP Position (mm) [-posterior, +anterior]
Lateral
5.0
0.0
66%
33%
HS
TO
Fig. 15.2 AP translation pattern of the medial and lateral femoral condyles during the stance
phase of gait in the healthy, non-implanted knee (HS, heel strike; 33% of stance phase; 66% of
stance phase; TO, toe off)
–5.0
–10.0
–15.0
–20.0
D. A. Dennis et al.
direction more than the medial femoral condyle (MFC), representing a fan-like
motion pattern. Although it has been described the normal knee exhibits a medial
pivot pattern, the data does not precisely resemble this type of motion as the medial
condyle translates in the sagittal plane up to 12mm during motion cycles. The magnitude of posterior translation during the stance phase of gait averages 5.8mm laterally vs. 0.4mm medially (Fig.15.2). During the entire gait cycle (stance and swing
phases), when the direction of knee exion angle changes from extension to exion,
the lateral condyle translates in the posterior direction. When the angle changes
from exion into extension, the lateral condyle contact point translates anteriorly.
During a WB-DKB using dynamic video uoroscopy, the magnitude of AP
translation is higher as compared to normal gait, which incurs a lesser degree of
knee exion. Mueller etal. [28] have demonstrated that 102 of 104 subjects with a
normal knee analyzed under uoroscopic surveillance while performing a DKB
experienced some degree of posterior motion for the MFC, and all 104 experienced
posterior motion of the LFC (Fig.15.3). The medial fan-like kinematic pattern is
more consistently present during a WB-DKB as compared to normal gait [29, 32–34].
Freeman etal. has described the normal knee having a medial pivot motion pattern, based on an MRI analysis where the patient was lying on their back and the
knee was moved passively, but stationary during each image [35]. The lateral femoral condyle (LFC) predictably moved more posteriorly than the MFC.This is corroborated by the study of Johal et al. [36], in another non-weightbearing MRI
analysis that showed that during exion, the LFC moves posterior while the MFC
remains relatively more stationary. The MFC does exhibit some translational movement but is much more constrained than the LFC due to the articulation of a convex
33%
HS
66%
TO
15 Comparisons ofAll Designs withRespect totheCruciate Ligaments
Fig. 15.3 Top view of the fan-like pattern of AP translation of the medial and lateral femoral
condyles during a WB-DKB in the healthy, nonimplanted knee. Note that the MFC demonstrates
some posterior translation although less than the LFC
191
MFC with a concave medial tibial plateau, which produces a fan-like distribution of
motion [37]. Beyond 120° of exion during a WB-DKB activity, both condyles
move posteriorly to a similar extent.
Axial Rotation
During gait from heel strike to toe off, dynamic, weightbearing uoroscopic studies
have demonstrated that healthy-nonimplanted knees typically experience axial rotation, with the tibia internally rotating in reference to the femur with increasing knee
exion [28] (Fig.15.4a).
Tibial internal rotation with respect to the femur is also present in the nonimplanted normal knee during higher degrees of knee exion, such as during a
WB-DKB [8, 32, 36, 38]. The magnitudes of axial rotation are greater during a
WB-DKB than during normal gait due to the increased exion incurred during this
activity (Fig.15.4b).
The coupled internal tibia rotation as the femur exes and external tibial rotation
as the femur extends is referred to as the screw-home mechanism [39]. While various explanations exist to explain this axial rotation pattern, common hypotheses
include the length and tensioning of the cruciate and collateral ligaments, as well as
asymmetry in the geometry of the medial and lateral femoral condyles [39].
192
6
a
Axial Rotation (Degrees)
AXIAL ORIENTATION (
°) [-INT, +EXT]
0
KNEE FLEXION ANGLE (°)
D. A. Dennis et al.
4
2
0
–2
–4
–6
–8
0
20 40 60
Gait Cycle (%)
80 100
b
25.0
20.0
15.0
10.0
5.0
0.0
–5.0
–10.0
–15.0
–20.0
0306090120 15
Fig. 15.4 (a) Axial rotation pattern of the healthy, nonimplanted knee during gait. (b) Axial rota-
tion pattern of the healthy, nonimplanted knee during a WB-DKB