Purpose A balanced knee arthroplasty should optimise survivorship and performance. Equilibration of medial and lateral femorotibial load requires guided judicious pericapsular ligament release. The null hypothesis was that there would be no difference between use of a tensiometer device and a remote load sensor final load transfer across the joint through functional arc of motion. Methods A cadaveric study, using eight knees, was performed to define the impact of an established gap distraction device against load sensor-aimed soft tissue release in a TKA setting. Using validated measures of laxity in six degrees of freedom and true real-time load sensing four states were examined: native knee, TKA using spacer blocks (TKA), TKA with soft tissue release aided by a monogram tensiometer (TKA-T) and finally where load across the tibiofemoral articulation remains unbalanced final soft tissue release using a sensor device (TKA-OS). Results The laxity pattern was equivalent for TKA-T and TKA-OS. However, in only four of these seven knees despite the tensiometer confirming equivalence of rectangular flexion–extension gap dimensions and centralisation of collateral ligament distraction, there remained a > 15lb medial to lateral load difference for at least one point of the flexion arc. This was corrected by further final soft tissue release guided by the OS sensor device in the final three knees. Conclusion Tensiometer-guided soft tissue release at two points of flexion failed to achieve balance for three out of seven knee arthroplasty procedures. Sensor technology guided final soft tissue balancing to equilibrate load across the joint through full arc of motion. This work argues for the role of continuous sensor readings to guide the soft tissue balancing during total knee arthroplasty.

Purpose and hypothesisCorrect femoral component rotation at knee arthroplasty influences patellar tracking and may determine function at extremes of movement. Additionally, such malrotation may deleteriously influence flexion/extension gap geometry and soft tissue balancing kinematics. Little is known about the effect of subtle rotational change upon load transfer across the tibiofemoral articulation. Our null hypothesis was that femoral component rotation would not influence load across this joint in predictable manner. MethodsA cadaveric study was performed to examine load transfer using the orthosensor device, respecting laxity patterns in 6° of motion, to examine load across the medial and lateral compartments across a full arc of motion. Mixed-effect modelling allowed for quantification of the effect upon load with internal and external femoral component rotation in relation to a datum in a modern single-radius cruciate-retaining primary knee design. ResultsNo significant change in maximal laxity was found between different femoral rotational states. Internal rotation of the femoral component resulted in significant increase in medial compartment load transfer for knee flexion including and beyond 60°. External rotation of the femoral component within the limits studied did not influence tibiofemoral load transfer.ConclusionsInternal rotation of the femoral component will adversely influence medial compartment load transfer and could lead to premature polyethylene wear on the medial side.

Traditional balancing techniques may not reliably equate to uniform laxity or contact forces across the tibiofemoral joint through a range of flexion and argue for the role of per-operative sensor use to aid final balancing of the knee.

Modular uncemented acetabular components are in common use. Fixation is dependent upon press-fit but the forces necessary to achieve initial stability of the construct at implantation may deform the shell and prevent optimal seating of the polyethylene liner insert. Previous work using single-time point measurements in uncontrolled ambient temperature poorly replicates the native state. A controlled study was performed to observe the time-dependent behaviour of an uncemented acetabular shell in the early phase after implantation into the human acetabulum at near physiological temperature. Using a previously validated cadaveric hip model at controlled near physiological temperature with standardised surgical technique, immediate and delayed shell geometry was determined. Eight custom made 3-mm-thick titanium alloy (TiAl6V4) shells were implanted into four cadavers (eight hips). Time-dependent shell deformation was determined using the previously validated ATOS Triple Scan III (ATOS) optical measurement system. The pattern of change in the shape of the surgically implanted shell was measured at three time points after insertion. We found a consistent pattern for quantitative and directional deformation of the shells. In addition, there was consistency for relaxation of the deformation with time. Immediate mean change in shell radius was 104 µm (standard deviation 32, range 67-153) relaxing to mean 96 µm (standard deviation 32, range 63-150) after 10 min and mean 92 µm (standard deviation 28, range 66-138) after 20 min. The clinical significance of this work is the finding of a time-dependent early deformation of acetabular titanium shells on insertion adjusted for near physiological temperature-controlled host bone.

To gain initial stability for cementless fixation the acetabular components of a total hip replacement are press-fit into the acetabulum. Uneven stiffness of the acetabular bone will result in irregular deformation of the shell which may hinder insertion of the liner or lead to premature loosening. To investigate this, we removed bone cores from the ilium, ischium and pubis within each acetabulum and from selected sites in corresponding femoral heads from four cadavers for mechanical testing in unconfined compression. From a stress-relaxation test over 300 s, the residual stress, its percentage of the initial stress and the stress half-life were calculated. Maximum modulus, yield stress and energy to yield (resilience) were calculated from a load-displacement test. Acetabular bone had a modulus about 10-20%, yield stress about 25% and resilience about 40% of the values for the femoral head. The stress half-life was typically between 2-4 s and the residual stress was about 60% of peak stress in both acetabulum and femur. Pubic bone was mechanically the poorest. These results may explain uneven deformation of press-fit acetabular shells as they are inserted. The measured half-life of stress-relaxation indicates that waiting a few minutes between insertion of the shell and the liner may allow seating of a poorly congruent liner.