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214
G. R. Scuderi and A. J. Tria
in greater demands on the knee for a longer duration of time. Younger patients may
also have higher expectations in restoration of functional status after TKA with
desires to return to more physically demanding activities. TKA has proven to be a
predictable and durable procedure, returning patients to both activities of daily living and recreational activities with overall good survivorship. Satisfying patient
expectations is the ultimate goal. Despite advances in implant design and surgical
technique over the years, up to 20% of patients remain dissatised [3, 4]. However,
a recent review of the literature found that the average rate of patient dissatisfaction
was 10% [5]. What was interesting was that many sociodemographic factors, such
as nancial status, education, and non-White race, were associated with dissatisfaction, but may not be a direct cause but are associated with an increased risk of poor
outcomes through an associated relationship. As an example, the confounding differences with age nd that younger patients have a higher expectation of activity
following TKA with desires to return to more physically demanding activities,
while physiologically older patients have more medical comorbidities and may not
be as functionally active. Worse functional outcomes and postoperative complications contribute to patient dissatisfaction and will be the driving force for improvements in TKA design and technique. To further improve patient satisfaction, efforts
are needed to further reduce postoperative complications with a critical assessment
of the perioperative clinical pathway. Further improvements in implant design,
instrumentation, and surgical technique are evolving and are directed towards a
more personalized approach, which is expected to be assisted by innovative
technology.
Implant Design
The issue of patient dissatisfaction may be reduced by a more individualized patientspecic approach to TKA with more personalized designs and surgical technique.
The current inventory of modern implants is providing a wide range of shapes and
sizes with more anatomically shaped components. The systems now include closer
sizing of the femoral component with 2mm increments, with standard and narrow
options, allowing better t to the anterior-posterior dimension without overhang.
This more personalized t with off-the-shelf components allows for anatomic referencing while avoiding complications associated with anterior and posterior referencing techniques [6, 7]. The tibial component has seen designs with more anatomic
shapes that provide tibial coverage without compromise of the rotational position.
The main direction of newer TKA design is to optimize component t without compromise, improve knee kinematics by restoring the radii of femoral curvature,
improve patella tracking with a patella friendly trochlea and restore limb alignment.
There is currently a trending move away from the historical articular design and
towards more guided motion knee designs that replicate knee kinematics by the
geometry of the femoral tibial articular surface. We have seen from the American
Joint Replacement Registry [8] that while PCL substituting (PS) knee designs had
16 Future Considerations
been the most popular implant design, PCL retaining (CR) implants are gaining
popularity and are the most commonly implanted design. However, the recent AJRR
report also noted that there is an increased interest in guided motion knee implant
designs, such as the ultracongruent, medial congruent and medial pivot. These
newer implant designs may continue to erode on both the PS and CR market share.
It appears that the surface geometries, with differential medial and lateral conformities, in these designs inuences knee kinematics and motion without the need for
the cruciate ligaments or cam-post mechanism. What may be driving the increased
interest in guided motion knee designs is that it is coupled with the new interest in
alternative alignments in TKA, such as kinematic alignment in contrast to mechanical alignment.
215
Trends inAlignment
The advent of modern components and advanced technologies has fueled the debate
on whether mechanical alignment can be justied in all knees. Currently, a personalized approach to TKA has numerous novel schemes and techniques such as anatomic alignment, unrestricted kinematic alignment, restricted kinematic alignment,
inverse restricted kinematic alignment, adjusted mechanical alignment, and functional alignment. The nuances and language of knee alignment is differing and confusing. With each of these personalized alignments, the resection targets and
boundaries are individualized and varying without consistency. Some techniques
like kinematic alignment pose the risk of reproducing extreme native alignment
while restricted kinematic alignment imposes boundaries on implant positioning
and ultimate limb alignment. The range of variability between all proposed alignment techniques in targets for the hip knee angle (HKA); femoral and tibial coronal
alignment; femoral and tibial sagittal alignment; and femoral axial alignment is
wide and varying. There has yet to be an agreed upon personalized technique that
has been widely accepted as mechanical alignment [9]. Further research is needed
to assess the relevance of these “new” alignment schemes to see if they are really
worth the change and which ones are the most relevant for which patients, diagnoses, and degrees of deformity as noted with the coronal plane alignment of the knee
(CPAC) classication [10].
Instrumentation
Currently, the most common surgical technique for TKA is conventional manual
instrumentation with procedures following a similar plan. However, there has been
a shift to innovative technologies to assist in surgical accuracy. Studies have shown
that patient anatomy in three dimensions (3D) varies from patient to patient.
Advanced imaging and related technologies can better dene each patient’s specic
216
G. R. Scuderi and A. J. Tria
anatomic features. While computer navigation introduced the concept of a more
individualized approach based upon advanced imaging, this has evolved to roboticassisted surgery. The utility of standard radiographs for preoperative planning has
scrutinized as MRI and CT scans have been shown to offer greater detail and allow
for a virtual 3D reproduction of the knee. Current robotic systems create a 3D plan
based upon intraoperative bone morphology mapping or a preoperative MRI or CT
scan. Based upon the 3D reconstruction data collected, the personalized preoperative plan for the individual patient is created. The robotic-assisted surgery also
allows an assessment of ligament balancing based upon the bone cuts and implant
position. This has the potential to be further enhanced by collecting all the information into a large database and allow articial intelligence (AI) and machine learning
(ML) analysis of the alignment and outcome [11]. With the best aggregated clinical
results determined by ML, the computer can be programmed to learn how to make
the best recommendation for alignment of each patient, which is then incorporated
into the robotic surgical plan. The role of AI will continue to expand with ongoing
advances, pushing the boundaries of its capabilities. Incorporating ML has the
potential to elevate patient care by identifying the best preoperative patient parameters and postoperative pathways to help drive higher patient satisfaction.
One of the challenges of achieving a satisfactory TKA is ligament balancing.
Historically, ligament balance was a qualitative “feel” rather than a quantitative
measurement. This “feel is based upon surgeon experience but is inuenced by
many patient factors including degree of deformity or contracture, generalized ligament laxity, joint stiffness, obesity, and gender. The introduction of intraoperative
sensors with the surgical instrumentation provides intraoperative monitoring and
objective data to facilitate decision-making regarding implant position and soft tissue releases to improve balance and stability through the full range of motion [12].
Further development of real-time intraoperative sensors incorporated into tensiometers or robotic-assisted surgical system will need to dene the normal pressures, as
well as the normal ligament tension, within the joint to achieve a well-balanced
TKA.This information, along with ML analysis, has the potential to provide a personalized approach to ligament balance for each patient.
Augmented Reality
Augmented reality (AR), an interactive experience, where the knee that resides in
the real world is enhanced by computer generated information, is generating increasing interest as a technology that could improve the accuracy and efciency of TKA
[13, 14]. It has been shown that the accuracy of planned bone resection with the
assistance of AR matches the preplanned conguration with errors <1° regardless of
the target value [14]. This technology also has the potential for soft tissue balance
by direct real-time measurement of the strain of the collateral ligaments throughout
the range of motion by tracking their movements from their origins and insertions
[13]. Intraoperative ligament assessment can be used to establish a patient-specic
16 Future Considerations
217
plan, guiding the surgeon to the best target to achieve proper ligament balance with
the potential to improve clinical outcomes. While further research is needed, AR
may be the future of innovative technology in TKA instrumentation.
Smart Implants
Though in its infancy, smart implants with embedded sensor technology have the
potential to provide the quantitative invivo data to improve postoperative recovery,
reduce postoperative visits, detect early complications, and increase patient satisfaction [15]. The recent introduction of sensor technology within the Persona iQ
(Zimmer Biomet, Warsaw, IN) can detect activity and record kinematic data that can
characterize a patient’s physical recovery and provide diagnostic information. The
embedded inertial measurement unit collects step count, walking speed, stride
length, cadence, functional range of motion while walking and tibia range of motion.
Analysis of the collected data and recovery curves demonstrated that there are
patient-specic differences in their early postoperative course with discrete cohorts
[16]. Though there is currently limited clinical use of smart implants, it is expected
that we will see a growing trend of smart implants as there are renements in the
technology.
Summary
The knowledge and technology from our current experience in TKA is setting the
stage for future developments. Enhancements in our understanding of knee anatomy
and biomechanics are suggesting ways of improving outcomes and potentially
patient satisfaction. Applying this knowledge to implant designs that replicate the
anatomy of the knee and kinematics, along with more precise surgical techniques
with innovative technology will be the future of TKA.The immersion of augmented
reality devices into TKA may help provide enhanced real-world information at the
time of surgery, further rening the clinical outcome.
References
1. Shichman I, Roof M, Askew N, et al. Projections and epidemiology of primary hip and
knee arthroplasty in Medicare patients to 2040-2060. J Bone Joint Surg Open Acess.
2023;8:e22.00112. https://doi.org/10.2106/JBJS.OA22.00112.
2. Mahmoud K, Alagha MA, Nowinka Z, Jones G.Predicting total knee replacement at 2 and
5 years in osteoarthritis patients using machine learning. BMJ Surg Interv Health Technol.
2023;5:e000141. https://doi.org/10.1136/bmjsit- 2022- 000141.
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3. Noble PC, Conditt MA, Cook KF, Mathis KB.The John Insall Award: patient expectations
affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res. 2006;452:35–43.
4. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient satisfaction after total knee arthroplasty: who is satised and who is not? Clin Orthop Relat Res.
2010;468:57–63.
5. DeFrance MJ, Scuderi GR. Are 20% of patients actually dissatised following total knee
arthroplasty? A systematic review of the literature. J Arthroplast. 2023;38:594–9.
6. Knapp PW, Scuderi GR.Anatomic referencing restores the anatomy of the distal femur with
less compromise. J Knee Surg. 2024;37(2):114–20. https://doi.org/10.1055/a- 2186- 6087.
7. Campbell BR, Weinberg M, Bischoff J, Scuderi GR.An evaluation of anatomic referencing for
femoral component sizing using CT based computer modeling. J Knee Surg. 2024;37:638–41.
https://doi.org/10.1055/a- 2240- 3566.
8. American Joint Replacement Registry annual report 2022.
9. MacDessi SJ, Oussedik S, Abdel MP, Victor J, Pagnano MW, Haddad FS. The language of
knee alignment. Updated denitions and considerations for reporting outcomes in total knee
arthroplasty. Bone Joint J. 2023;105B(2):102–8.
10. MacDessi SJ, Grifths-Jones W, Harris IA, Bellemans J, Chen DB.Coronal plane alignment
of the knee (CPAK) classication. Bone Joint J. 2021;103-B(2):329–37.
11. Myers TG, Ramkumar PN, Ricciardi BF, Urish KL, Kioper J, Ketonis C.Articial intelligence,
and orthopedics: an introduction for clinicians. J Bone Joint Surg Am. 2020;102(9):830–40.
12. Batailler C, Swan J, Marinier ES, Servien E, Lustig S.New technologies in knee arthroplasty:
current concepts. J Clin Med. 2021;10:47. https://doi.org/10.3390/jcm10010047.
13. Fucentese SF, Koch PP.A novel augmented reality based surgical guidance system for total
knee arthroplasty. Arch Orthop Trauma Surg. 2021;141:2227–33.
14. Castellarin G, Bori E, Barbieux E, Grandjean VP, Jost G, Innocenti B.Is total knee arthroplasty
surgical performance enhanced using augmented reality? A single-center study on 76 consecutive patients. J Arthroplast. 2024;39:332–5.
15. Kelmers E, Szuba A, King SW, etal. Smart knee implants: An overview of current technologies and future possibilities. Indian J Orthop. 2023;57:635–42.
16. Cushner FD, Yergler J, Elashoff BA, Aubin PD, Scuderi GR.Staying ahead of the curve– the
case r recovery curves in total knee arthroplasty. J Arthroplast. 2024; https://doi.org/10.1016/j.
arth.2024.07.039.
G. R. Scuderi and A. J. Tria
Index
A
ACL decient (ACLD), 100–102,
108, 193–195
ACL preserving knee (XR), 142
ACL reconstruction, 103, 109
Active robotic systems, 154
American Joint Replacement Registry
(AJRR), 53, 214
The American Society for Testing and
Materials (ASTM), 32
Anterior cruciate ligament (ACL), 19, 20, 38,
52, 82, 124
Anterior-posterior (AP) tibial resection, 106
Anteromedial osteoarthritis (AMOA),
99–101, 110
AP femorotibial translation, 186
Arthroscopic debridement, 93
Articial intelligence (AI), 213, 216
Articial intelligence technique, 163–168
See also Robotic-assisted TKA
Augmented reality (AR), 216, 217
Australian Orthopaedic Association National
Joint Replacement Registry
(AOANJRR), 133
B
Bicruciate retaining (BCR), 179
Bi-cruciate retaining (BCR) designs, 9
Bicruciate retaining total knee arthroplasty
(BCR TKA), 200–202
advanced rehabilitation protocols, 92
advantages, 94
cementing the tibial component, 93
complications, 93, 94
disadvantages, 95
duocondylar knee prosthesis, 90
history, 89
medial and patellofemoral
compartments, 91
monolithic design, 91
prosthetic designs, 90, 91
results, 93–95
surgical technique, 92, 93
unconstrained surfaces, 89
unicondylar concept, 91
Bicruciate stabilized (BCS), 179, 180
Bicruciate substituting total knee arthroplasty
(BCS TKA), 199–201
clinical outcomes, 84–86
design features, 83, 84
native knee kinematics, 81, 82
Bi-Uni approach, 142
C
Computer and robotic-assisted surgical
methods, 146
Computer-controlled replacements, 90
CORI surgical system, 164
Coronal plane alignment of the knee
(CPAK), 83–84
CR-TKA design, 53, 55
Cruciate ligaments
of knee
ACL, 19, 20
collateral ligaments, 22
femoral surfaces, 23, 24
middle genicular artery, 21
nerve receptors, 22
patellar surfaces, 23, 25
PCL, 20, 21
proprioception, 22
surface anatomy, 23, 24
tibial surfaces, 23, 25
properties and and implications, 33–37
© The Editor(s) (if applicable) and The Author(s), under exclusive license to
Springer Nature 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
219
220
Index
Cruciate retaining (CR), 51, 61, 147
Cruciate-retaining technique, 54
Cruciate retaining total knee (CR knee), 73
Cruciate retention, articial knees with, 37–40
Cultural inuence, 10, 11
D
Decision-making process, 147
Dual orthogonal uoroscopy, 62
Duopatellar prosthesis, 6
E
Enhanced Recovery After Surgery (ERAS)
protocols, 173
F
Femoral Condylar Lift-off, 186, 193,
195, 197–199
First-generation BCS TKA, 86
Forgotten joint scores (FJS), 118
Four-bar link theory, 62
Freeman-Swanson knee design, 40
Functional alignment approach, 166
G
Gait analysis, 27
Gap balancing technique
ACL preserving knee systems, 142, 143
advantages, 139
axial malrotation, 144, 145
disadvantages, 139, 140
electronic ligament balancing device, 143
extension rst technique, 137, 138
femoral component rotation results, 136
exion and extension, 133–135
exion rst technique, 138, 139
future technologies, 143
gap philosophy, 141, 142
history, 136
joint distraction variability, 145, 146
measured resection technique, 134, 139
mechanical limb alignment, 140
optimal implant design, 147
robotic and constant gap distraction
technologies, 146
robotics, 146, 147
soft tissue balancing, 133
Geomedic knee, 90
Goniometer, 122, 123
Guided motion knee designs, 214
H
High speed stereoradiography, 33
Hospital for special surgery (HSS), 78
I
Imperial College London Hospital
(ICLH) knee, 4
Implant design, 214
Innervation, 22
Insall-Burstein I, 7
Insall-Burstein II prosthesis, 8
Insall-Burstein Knee (IB Knee), 74, 76
Instability, 133, 134, 145
Instrumentation, 215, 216
Intraoperative ligament assessment, 216
In vivo dynamic radiostereometric analysis, 67
In vivo evidence, 117
In-vivo uoroscopic evaluation, 124
In vivo video uoroscopic techniques, 186
K
Kinematic alignment technique, 140
Kinematically aligned (KA) total knee
arthroplasty
ACL stability restoration, 124
advantages, 118
denition, 118
lateral at articular surface restores I-E
tibial rotation, 126–128
medial 1
1 ball-in-socket conformity, 126
PCL retention promotes internal tibial
rotation, 125, 126
performance
accuracy with manual instruments, 119
balancing, spacer block and insert
goniometer, 122, 123
pre-arthritic femur
resurfacing, 119–121
pre-arthritic tibia resurfacing, 119,
121, 122
tibial external orientation, in extension
tightens LCL, 124, 125
tibial internal orientation, 125
Kinematic analysis of modern TKA designs
ACL-decient, 193–195
BCR, 200–202
BCS, 199–201
healthy, non-implanted, 189–193
medial pivot, 202, 203
mobile-bearing, 203, 204
PCL sparing, 195–197
Index
221
PCL substituting, 197, 198
ROM, 204, 205
Kinematics of knee
for articial knees with cruciate
retention, 37–40
cruciate function, 40–43
cruciate ligaments and implications, 33–37
degrees of freedom, 30
exion-extension axis, 30
gait analysis, 27
Grood-Suntay system, 29
history, 27
initial basic design, 32
kinematic analysis of modern TKA designs
(see Kinematic analysis of modern
TKA designs) (see also Knee
kinematics)
laxity, 31, 32
Mobile uoro units, 28
neutral path of motion, 36
quadriceps muscle and patella, 32
relative position and motion, 29
three-dimensional motion, 30
transverse axis, 30, 31
transverse rotations, 27
use of uoroscopy, 32, 33
Knee kinematics
native of, 81, 82
role of cruciates in, 64
theories of, 62, 63
Knee society scores (KSS), 78, 86
L
Lateral collateral ligament (LCL), 22, 23, 124,
125, 134
Laxity, 31, 32
Legacy posterior stabilized high exion
prosthesis (LPS Flex), 75
Legacy posterior stabilized prosthesis
(LPS), 74
Ligament balancing, 139
Low contact stress (LCS), 11
M
Machine learning (ML), 216
Mako Robotic-Arm Assisted System, 164, 167
Measured resection technique, 134, 139
Medial collateral ligament (MCL), 22, 24, 124
Medial femoral condyle (MFC), 190
Medial parapatellar approach, 68, 175
Medial pivot (MP) TKA, 202, 203
advanced technologies and future
directions, 69
history and rationale, 64, 65
implant design, 65–67
ball and socket medial
compartment, 66, 67
multi-radius/J-curve design, 65
single radius, 67
outcomes of, 68, 69
surgical technique, 68
Middle genicular artery, 21
Mobile-bearing (MB) TKA, 203, 204
Monolithic design, 91
MP TKA designs, 85
N
Neuromuscular electric stimulation
(NMES), 176
Newer TKA design, 214
O
Oxford Knee Rig, 32
Oxford Knee Scores (OKS), 118
P
Paradoxical anterior femoral translation,
193
“Paradoxical anterior motion”, 66
“Paradoxical motion”, 61
Partial knee arthroplasty
clinical outcomes
medial UKA and combined ACL
reconstruction, 109
medial UKA in ACL deciency, 108
medial UKA in ACL-intact, 107
medial UKA in PCL deciency, 110
criteria for, 102, 103
history, 99, 100
pathoanatomy, 100–102
prosthetic design, 103, 104
surgical technique, 105–107
Partial knee replacement, 177
Passive systems, 154
PCL-sparing TKA
clinical outcomes, 55, 56
femoral rollback, 52, 53, 56
PS total knee design, 53, 54
role of, 52, 53
surgical approach and technique, 54, 55
Polycentric TKA, 9
222
Index
Posterior cruciate ligament (PCL), 4, 12, 20,
21, 34, 35, 51, 73, 82, 118
cruciate-retaining technique, 54
bers, 21
integrity, 122
sparing TKA, 195–197
substituting TKA, 197, 198
Posterior cruciate ligament (PCL)
deciency, 110
Posterior cruciate–retaining. (PCR) TKA,
186, 197
Posterior cruciate stabilized (PS), 61
Posterior stabilized (PS), 3, 5–7, 147
Posterior stabilized total knee arthroplasty (PS
Knee), 73
complications, 77
design principles and kinematics, 76
history, 74, 76
indications for, 76
outcomes, 78
surgical technique, 77
Posteromedial osteoarthritis
(PMOA), 101–102
Proprioception, 22
R
Radio-stereometric analysis (RSA), 118
Randomized controlled trials (RCTs), 68
Range of motion (ROM), 55, 73, 89, 176,
204, 205
Rehabilitation, TKA, 39
guidelines, 175–177
implant
BCR, 179
BCS, 179, 180
xation, 177
medial pivot TKA design, 180
partial knee replacement, 177
PCL retaining, 178, 179
PCL substituting/stabilized, 178
implant xation, 177
overview, 173–175
surgical approaches, 175
Reverse axial rotation (AR), 186
Revision TKA (rTKA), 133
ROBODOC, 163
Robotic-assisted TKA
alignment strategies, 165, 166
clinical studies
outcomes, 158
precision and component placement,
157, 158
soft-tissue protection, 158
cruciate retaining implants and, 166
data capture, 167, 168
different surgical robots and
features, 163–165
indication, 153
limitations, 159
potential for articial intelligence, 168
system features
active, 154
image-based versus imageless, 154
open versus closed, 155
passive, 154
semi-active, 154
technique
femoral and tibial cuts, 157
intraoperative planning, 157
preparation and approach, 155
registration and surface mapping,
155, 157
Robotic-enabled functional alignment
approach, 166
Robotics, 90, 146
Rosa knee system, 165
S
Sagittal radius design, 67
“Screw-home mechanism”, 63
Second generation BCS TKA, 84, 86
“Second generation” medial pivot designs, 67
Semi-active systems, 154
Semi-autonomous systems, 164
Smart implants, 217
Soft tissue balancing, 139
Soft tissue management, 84
Sub-vastus approach, 175
Surgeon dened assessment (SDA), 135
T
Three-dimensional magnetic resonance
imaging, 62
Tibiofemoral joint, 62
Total Condylar (TC) knee prosthesis, 4, 5, 8
Total Condylar Prosthesis (TCP), 74
Total Condylar Prosthesis II (TCP II), 6
Total knee arthroplasty (TKA), 43, 51–56,
61–70, 73–78, 81–86, 89–96, 99,
107, 118, 120, 134, 140, 155, 156,
159, 168, 176, 177, 179, 185
See also Medial pivot TKA
Total knee replacements
BCR designs, 9, 10
Index
223
conception and design of condylar
total knee, 3
cruciate retaining, 7–9
cultural inuence, 10, 11
Duocondylar knee, 4, 5
ICLH knee, 4
Insall-Burstein I, 7
Insall-Burstein II prosthesis, 8
polyethylene advancements, 11, 12
posterior stabilized, 5–7
Transepicondylar axis (TEA), 138
Trends in alignment, 215
U
Ultra-congruent (UC), 61
Ultra-congruent (UC) TKA, 56
Unicompartmental arthroplasty (UKA)
clinical outcomes
medial UKA and combined ACL
reconstruction, 109
medial UKA in ACL deciency, 108
medial UKA in ACL-intact, 107
medial UKA in PCL deciency, 110
criteria for, 102, 103
history, 99, 100
pathoanatomy, 100, 102
prosthetic design, 103, 104
surgical technique, 105–107
Unicompartmental knee arthroplasty
(UKA), 153
Unicompartmental knee replacement
(UKA), 177
Unicondylar knee prostheses (UKA), 89
V
VELYS Robotic-Assisted Solution, 165
Video uoroscopy, 186
W
Weight-bearing deep knee bends (WB-DKB),
186, 188–190, 195, 196
X
xyz Cartesian axis system, 29