Abstract
Introduction
Despite the existence of diverse total knee implant designs, few data is available on the relationship between the level of implant constraint and the postoperative joint stability in the frontal plane and strain in the collateral ligaments. The current study aimed to document this relation in an ex vivo setting.
Materials and methods
Six fresh-frozen lower limbs underwent imaging for preparation of specimen-specific surgical guides. Specimens were dissected and assessed for joint laxity using the varus–valgus stress tests at fixed knee flexion angles. A handheld dynamometer applied tensile loads at the ankle, thereby resulting in a knee abduction–adduction moment of 10 Nm. Tibiofemoral kinematics were calculated using an optical motion capture system, while extensometers attached to medial collateral (MCL) and lateral collateral ligament (LCL) measured strain. Native joint testing was followed by four TKA designs from a single implant line—cruciate retaining, posterior stabilised, varus–valgus constrained and hinged knee (HK)—and subsequent testing after each implantation. Repeated measures linear mixed-models (p < 0.05) were used to compare preoperative vs. postoperative data on frontal plane laxity and collateral ligament strain.
Results
Increasing implant constraint reduced frontal plane laxity across knee flexion, especially in deep flexion (r2 > 0.76), and MCL strain in extension; however, LCL strain reduction was not consistent. Frontal plane laxity increased with knee flexion angle, but similar trends were inconclusive for ligament strain. HK reduced joint laxity and ligament strain as compared to the native condition consistently across knee flexion angle, with significant reductions in flexion (p < 0.024) and extension (p < 0.001), respectively, thereby elucidating the implant design-induced joint stability. Ligament strain exhibited a strong positive correlation with varus–valgus alignment (r2 = 0.96), notwithstanding knee flexion angle or TKA implant design.
Conclusion
The study demonstrated that increasing the constraint of a TKA resulted in lower frontal plane laxity of the knee. With implant features impacting laxity in the coronal plane, consequentially affecting strain in collateral ligaments, surgeons must consider these factors when deciding a TKA implant, especially for primary TKA.
Level of evidence
V.
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Acknowledgements
The authors gratefully acknowledge the contributions of Mr. Kristof Reyniers and Mr. Jo Verbinnen in preparing the specimens.
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Smith and Nephew provided financial support and contributed to the study design and data collection.
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PB was involved in the study design, data acquisition, data interpretation, manuscript preparation and manuscript review. DSS was involved in the data analysis, data interpretation, manuscript preparation and manuscript review. OT was involved in the study design, data acquisition, data analysis, data interpretation and manuscript review. JS was involved in the study design, data acquisition and manuscript review. RDC was involved in data interpretation and manuscript review. LS was involved in the study design, data interpretation and manuscript review. HV was involved in the study design, data interpretation and manuscript review. All authors have read and approved the manuscript.
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The author’s institution (IORT) receives research funding from Smith and Nephew. RD is an employee of Smith and Nephew. No other conflicts of interest.
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Ethical approval obtained for the cadaver study from the local research ethics committee (NH019, dated 2016-06-03).
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Berger, P., Shah, D.S., Taylan, O. et al. Impact of increasing total knee replacement constraint within a single implant line on coronal stability: an ex vivo investigation. Arch Orthop Trauma Surg 143, 2165–2173 (2023). https://doi.org/10.1007/s00402-022-04534-x
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DOI: https://doi.org/10.1007/s00402-022-04534-x