Is Femoral Component Rotation in a TKA Reliably Guided by the Functional Flexion Axis?

Oussedik, Sam; Scholes, Corey; Ferguson, Duncan; Roe, Justin; Parker, David

doi:10.1007/s11999-012-2515-0

Cited by 38 publications

(37 citation statements)

References 26 publications

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“…To maintain an even gap at 90° or higher flexion using s-TEA may need to consider the condyle height differences of the medial and lateral condyles. Recently, the GCA has been suggested as a reproducible and reliable reference to optimize femoral component positioning during TKA (Colle et al, 2012; Doro et al, 2008; Howell et al, 2013; Matziolis et al, 2011; Oussedik et al, 2012), since it is believed that the alignment of TKA with GCA could replicate normal knee kinematics, such as medial pivot motion, and could produce an appropriate ligament balance after TKA (Blaha, 2004; Blaha et al, 2003). The different height of the GCA at full extension and 90° of flexion may need to be considered for gap balance at the two position of the knee.…”

Section: Discussionmentioning

confidence: 99%

“…The transepicondylar axis (TEA) and the geometrical center axis (GCA) are widely used in knee joint kinematics analysis (Asano et al, 2001; Berger et al, 1993; Eckhoff et al, 2007; Li et al, 2013; Matsuda et al, 2003; Most et al, 2004; Oussedik et al, 2012; Victor et al, 2009). A TEA could be referred to the clinical TEA (c-TEA) or surgical TEA (s-TEA) based on the different bony landmarks used to define the axes on the medial femoral epicondyle (Berger et al, 1993; Griffin et al, 2000; Victor et al, 2009; Yoshino et al, 2001).…”

Section: Introductionmentioning

confidence: 99%

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In-vivo analysis of flexion axes of the knee: Femoral condylar motion during dynamic knee flexion

Tsai

Rubash

et al. 2016

Clinical Biomechanics

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Background Transepicondylar axis and geometrical center axis are widely used for investigation of the knee kinematics and component alignment in total knee arthroplasty. However, the kinematic characteristics of these knee axes are not well defined in literature. This study investigated the femoral condylar motion during a dynamic flexion of the knee using different flexion axes. Methods Twenty healthy knees (10 males and 10 females) were CT scanned to create 3D anatomic models. The subjects performed a single leg flexion from full extension to maximal flexion while the knees were imaged using fluoroscopes. The femoral condyle translations in anterior-posterior and proximal-distal directions were described using clinical transepicondylar axis, surgical transepicondylar axis and geometrical center axis. Findings The subjects achieved −9.4° (SD 3.0°) hyperextension at full extension and 116.4° (SD 9.0°) at maximal flexion of the knee. The anterior-posterior translations of the three flexion axes were different for the medial condyle, but similar for the lateral condyle. Substantial variations of the condylar motion in proximal-distal direction were measured along the flexion path using these axes. While the surgical transepicondylar axis maintained condyle heights from full extension to 60° of flexion, geometrical center axis showed little changes in condyle heights from 30° to maximal knee flexion. The condyles moved distally beyond 90° flexion using both transepicondylar axes. Interpretation The femoral condylar motion measurement is sensitive to the selection of flexion axis. The different kinematic features of these axes provide an insightful reference when selecting a flexion axis in total knee arthroplasty component alignment.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

In-vivo analysis of flexion axes of the knee: Femoral condylar motion during dynamic knee flexion

Tsai

Rubash

et al. 2016

Clinical Biomechanics

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“…This is because the rotational alignment of the femoral component not only affects tracking of the patellar component but also determines the flexion gap of the femoral component [ 2 , 13 ]. Previous studies suggested using the posterior condylar axis (PCA) [ 12 ], Whiteside’s line [ 18 ] or the transepicondylar axis (TEA) [ 9 , 11 , 14 , 20 ] as a reference axis for determining rotational alignment of the femoral component, and there have been studies on the angles created between these reference axes [ 8 , 12 , 15 , 16 , 18 ]. However, it is not always easy to apply such traditional references in the operative field because arthritic changes such as deformities, bony defects and osteophytes not only make it difficult to identify these references but also distort them [ 3 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

Comparison of alternate references for femoral rotation in female patients undergoing total knee arthroplasty

Jin

Han

et al. 2015

Knee Surg Sports Traumatol Arthrosc

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PurposeAccurate rotational alignment of the femoral component is of vital importance for successful total knee arthroplasty (TKA). Two anatomical references located on the anterior femur were recently introduced. To determine which is more reliable reference axis for the femoral component rotation in female patients receiving TKA, the trochlear anterior line was compared with the femoral anterior tangent line.Materials and methodsPreoperative computed tomography in 76 patients receiving TKA for varus deformity was performed, and the images were reconstructed into three-dimensional models. The trochlear anterior line was defined as the line connecting the most anterior portion of the lateral and medial femoral condyles and the femoral anterior tangent line as the line parallel to distal anterior femoral surface. The two angles between these reference axes and the surgical transepicondylar axis (TEA) in three-dimensional images (trochlear anterior line/TEA, femoral anterior tangent line/TEA) were measured. The correlation between these two angles was computed. We investigated to see whether a significant difference in variance existed.ResultsThe trochlear anterior line was internally rotated by 6.1° ± 2.5° with respect to TEA, whereas the femoral anterior tangent line by 9.5° ± 3.8°. The trochlear anterior line was externally rotated by 3.4° ± 3.3° with respect to the femoral anterior tangent line. There was a significant correlation between the trochlear anterior line/TEA and the femoral anterior tangent line/TEA.ConclusionsThe variance of the trochlear anterior line/TEA was significantly smaller than that of the femoral anterior tangent line/TEA demonstrating a more consistent distribution. When conventional reference axes such as the posterior condylar axis or the anteroposterior axis are unclear or differ, surgeons can rely on these alternative references. When trochlear anterior line and femoral anterior tangent line contradicts, the former might be more reliable for the rotational alignment of the femoral component in female patients. Level of evidenceCase series with no comparison group, Level IV.

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“…Based on anatomical and kinematic data, the accepted gold standard for correct femoral component rotation is the SEA measured on a CT scan [ 2 , 4 , 11 , 28 , 30 ]. Unfortunately, both epicondyles are relatively broad structures covered in dense soft tissue in vivo making them difficult to identify intraoperatively [ 3 , 22 , 39 ].…”

Section: Introductionmentioning

confidence: 99%

The sulcus line of the trochlear groove is more accurate than Whiteside’s Line in determining femoral component rotation

Talbot

Dimitriou

Radic

et al. 2014

Knee Surg Sports Traumatol Arthrosc

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Purpose The sulcus line (SL) is a three-dimensional curve produced from multiple points along the trochlear groove. Whiteside’s Line, also known as the anteroposterior axis (APA), is derived from single anterior and posterior points. The purposes of the two studies presented in this paper are to (1) assess the results from the clinical use of the SL in a large clinical series, (2) measure the SL and the APA on three-dimensional CT reconstructions, (3) demonstrate the effect of parallax error on the use of the APA and (4) determine the accuracy of an axis derived by combining the SL and the posterior condylar axis (PCA).MethodsIn the first study, we assessed the SL using a large, single surgeon series of consecutive patients undergoing primary total knee arthroplasties. The post-operative CT scans of patients (n = 200) were examined to determine the final rotational alignment of the femoral component. In the second study, measurements were taken in a series of 3DCT reconstructions of osteoarthritic knees (n = 44).Results The mean position of the femoral component in the clinical series was 0.6° externally rotated to the surgical epicondylar axis, with a standard deviation of 2.9° (ranges from −7.2° to 6.7°). On the 3DCT reconstructions, the APA (88.2° ± 4.2°) had significantly higher variance than the SL (90.3° ± 2.7°) (F = 5.82 and p = 0.017). An axis derived by averaging the SL and the PCA+3° produced a significant decrease in both the number of outliers (p = 0.03 vs. PCA and p = 0.007 vs. SL) and the variance (F = 6.15 and p = 0.015 vs. SL). The coronal alignment of the SL varied widely relative to the mechanical axis (0.4° ± 3.8°) and the distal condylar surface (2.6° ± 4.3°).ConclusionsThe multiple points used to determine the SL confer anatomical and geometrical advantages, and therefore, it should be considered a separate rotational landmark to the APA. These findings may explain the high degree of variability in the measurement of the APA which is documented in the literature. Combining a geometrically correct SL and the PCA is likely to further improve accuracy.

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Is Femoral Component Rotation in a TKA Reliably Guided by the Functional Flexion Axis?

Cited by 38 publications

References 26 publications

In-vivo analysis of flexion axes of the knee: Femoral condylar motion during dynamic knee flexion

In-vivo analysis of flexion axes of the knee: Femoral condylar motion during dynamic knee flexion

Comparison of alternate references for femoral rotation in female patients undergoing total knee arthroplasty

The sulcus line of the trochlear groove is more accurate than Whiteside’s Line in determining femoral component rotation

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