The superficial medial collateral ligament is the primary medial restraint to knee laxity after cruciate-retaining or posterior-stabilised total knee arthroplasty: effects of implant type and partial release

Athwal, Kiron K.; Daou, Hadi El; Kittl, Christoph; Davies, Andrew; Deehan, David J.; Amis, Andrew A.

doi:10.1007/s00167-015-3796-0

Cited by 24 publications

(25 citation statements)

References 48 publications

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“…The loads applied in this study were similar to other in vitro TKA studies, yielding similar laxities [2, 24]. Saeki et al [31] found that under 35 N AP force, 10 Nm VV, and 1.5 Nm IE torques, MCL release increased laxity in cruciate-retaining TKA knees throughout flexion.…”

Section: Discussionsupporting

confidence: 81%

An in vitro analysis of medial structures and a medial soft tissue reconstruction in a constrained condylar total knee arthroplasty

Athwal

Daou

Inderhaug

et al. 2016

Knee Surg Sports Traumatol Arthrosc

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PurposeThe aim of this study was to quantify the medial soft tissue contributions to stability following constrained condylar (CC) total knee arthroplasty (TKA) and determine whether a medial reconstruction could restore stability to a soft tissue-deficient, CC-TKA knee.MethodsEight cadaveric knees were mounted in a robotic system and tested at 0°, 30°, 60°, and 90° of flexion with ±50 N anterior–posterior force, ±8 Nm varus–valgus, and ±5 Nm internal–external torque. The deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) were transected and their relative contributions to stabilising the applied loads were quantified. After complete medial soft tissue transection, a reconstruction using a semitendinosus tendon graft was performed, and the effect on kinematic behaviour under equivocal conditions was measured.ResultsIn the CC-TKA knee, the sMCL was the major medial restraint in anterior drawer, internal–external, and valgus rotation. No significant differences were found between the rotational laxities of the reconstructed knee to the pre-deficient state for the arc of motion examined. The relative contribution of the reconstruction was higher in valgus rotation at 60° than the sMCL; otherwise, the contribution of the reconstruction was similar to that of the sMCL.ConclusionThere is contention whether a CC-TKA can function with medial deficiency or more constraint is required. This work has shown that a CC-TKA may not provide enough stability with an absent sMCL. However, in such cases, combining the CC-TKA with a medial soft tissue reconstruction may be considered as an alternative to a hinged implant.

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Section: Discussionsupporting

confidence: 81%

An in vitro analysis of medial structures and a medial soft tissue reconstruction in a constrained condylar total knee arthroplasty

Athwal

Daou

Inderhaug

et al. 2016

Knee Surg Sports Traumatol Arthrosc

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“…The LCL was also found to contribute approximately 16% to resisting tibial anterior translation across flexion angles, a larger role than that previously found in native knees . This finding, along with a prior study into the contribution of medial soft tissues in TKA, suggests that in the absence of the anterior cruciate ligament the collaterals must provide a larger anterior restraint in implants with low conforming articular surfaces.…”

Section: Discussionmentioning

confidence: 48%

“…The knee was manually flexed 20 times to minimize soft tissue hysteresis and then tested in a robotic testing system previously described . The femur was fixed rigidly to the base of the robot and the tibia was mounted to the force/torque sensor on the end‐effector of the manipulator.…”

Section: Methodsmentioning

confidence: 99%

“…A custom Matlab (Mathworks, Natick, MA) script was used to calculate the mean peak forces/torques, translations/rotations, and soft tissue contributions (defined as the drop in force/torque after the transection/release as a percentage of the original force/torque value) from the three repeats. A power calculation, based on a mean difference in AP translation of 3.5 ± 3 mm and VV rotation of 3.7 ± 3.2° in a prior study, determined a minimum sample size of eight would be needed to detect a significant change in laxity between the native and implanted state with 80% power and 95% confidence. The following statistical analysis was performed in SPSS 22 (IBM SPSS Statistics, version 22, Armonk, NY): Two‐way repeated‐measures analysis of variance (RM‐ANOVA) was performed to compare laxities to the knee state (native and implanted knee) across different flexion angles. One‐way RM‐ANOVA was performed at each flexion angle to compare the force/torque contribution to the lateral structure cut. …”

Section: Methodsmentioning

confidence: 99%

“…The p ‐values reported have been adjusted in SPSS by multiplying by the appropriate Bonferroni correction factor, and thus the significance level was set at p < 0.05. A second power analysis (based on the same previous study) determined that, given the number of specimens and expected standard deviations, soft‐tissue contributions of 9% could be detected with 80% power and 95% confidence . Therefore, it was decided that for a restraint at a given flexion angle to be deemed significant, it must have a mean resisting contribution greater than a threshold value of 10% with p < 0.05.…”

Section: Methodsmentioning

confidence: 99%

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Lateral soft-tissue structures contribute to cruciate-retaining total knee arthroplasty stability

et al. 2016

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Little information is available to surgeons regarding how the lateral structures prevent instability in the replaced knee. The aim of this study was to quantify the lateral soft-tissue contributions to stability following cruciate-retaining total knee arthroplasty (CR TKA). Nine cadaveric knees were tested in a robotic system at full extension, 30°, 60°, and 90° flexion angles. In both native and CR implanted states, ±90 N anterior-posterior force, ±8 Nm varus-valgus, and ±5 Nm internal-external torque were applied. The anterolateral structures (ALS, including the iliotibial band), the lateral collateral ligament (LCL), the popliteus tendon complex (Pop T), and the posterior cruciate ligament (PCL) were transected and their relative contributions to stabilizing the applied loads were quantified. The LCL was found to be the primary restraint to varus laxity (an average 56% across all flexion angles), and was significant in internal-external rotational stability (28% and 26%, respectively) and anterior drawer (16%). The ALS restrained 25% of internal rotation, while the PCL was significant in posterior drawer only at 60° and 90° flexion. The Pop T was not found to be significant in any tests. Therefore, the LCL was confirmed as the major lateral structure in CR TKA stability throughout the arc of flexion and deficiency could present a complex rotational laxity that cannot be overcome by the other passive lateral structures or the PCL. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1902-1909, 2017.

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Evaluation of a novel robotic testing method for stability and kinematics of total knee arthroplasty

Holthof,

Rock,

van Arkel

et al. 2024

Knee surg. sports traumatol. arthrosc.

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PurposeThis work developed a novel preclinical test of total knee replacements (TKRs) in order to explain TKR instability linked to patient dissatisfaction. It was hypothesized that stability tests on the isolated moving prostheses would provide novel comparative data on the stability and kinematics among TKR designs.MethodsThree TKR designs, DePuy Synthes Attune MS, Stryker Triathlon and Zimmer Biomet Persona MC, were assessed using a robotic arm while flexing–extending 0–140°. Tests imposed 710 N body weight combined with three tibial loads: no anterior–posterior (AP) force, 90 N anterior or 90 N posterior force. Other load effects were minimized and the kinematics was recorded. Each implant was tested six times to investigate the repeatability of the method. Data were analysed using statistical parametric mapping with one‐way analysis of variance (ANOVA). If significance was found (p < 0.05), post hoc t tests with Bonferroni correction were used to contrast groups.ResultsSignificant differences were found throughout flexion–extension. Femoral rollback, AP stability, coupled internal–external rotation and AP position (roll‐back) were all influenced by implant design. AP stability of the TKRs reduced with flexion reaching Attune 15 mm, Persona 13 mm and Triathlon 21 mm at 140° flexion. Tractive rolling significantly affected kinematics in the less congruent Triathlon design, with 6 mm different paths between flexion and extension motion (p < 0.05 across 5–100°). Paradoxical anterior femoral sliding in early flexion (0–40°) occurred in Persona and Triathlon designs.ConclusionsThe novel testing technique provides, for the first time, comparative data on the inherent stability and kinematics of the TKR implants themselves across the arc of flexion–extension, independent of variables including soft tissue behaviour and surgical technique. The data show how much each prosthesis can contribute to the stability and motion of the implanted knee. Similar data from a wider range of designs will enable more informed decisions regarding implant design choice, aiming to reduce the prevalence of TKR instability in patients.Level of EvidenceControlled laboratory study.

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The superficial medial collateral ligament is the primary medial restraint to knee laxity after cruciate-retaining or posterior-stabilised total knee arthroplasty: effects of implant type and partial release

Cited by 24 publications

References 48 publications

An in vitro analysis of medial structures and a medial soft tissue reconstruction in a constrained condylar total knee arthroplasty

An in vitro analysis of medial structures and a medial soft tissue reconstruction in a constrained condylar total knee arthroplasty

Lateral soft-tissue structures contribute to cruciate-retaining total knee arthroplasty stability

Evaluation of a novel robotic testing method for stability and kinematics of total knee arthroplasty

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