Aims. The aim of this study was to compare a bicruciate-retaining (BCR) total knee arthroplasty (TKA) with a posterior cruciate-retaining (CR) TKA design in terms of kinematics, measured using fluoroscopy and stability as micromotion using radiostereometric analysis (RSA). Methods. A total of 40 patients with end-stage osteoarthritis were included in this randomized controlled trial. All patients performed a step-up and lunge task in front of a monoplane fluoroscope one year postoperatively. Femorotibial contact point (CP) locations were determined at every flexion angle and compared between the groups. RSA images were taken at baseline, six weeks, three, six, 12, and 24 months postoperatively. Clinical and functional outcomes were compared postoperatively for two years. Results. The BCR-TKA demonstrated a kinematic pattern comparable to the natural knee’s screw-home mechanism in the step-up task. In the lunge task, the medial CP of the BCR-TKA was more anterior in the early flexion phase, while laterally the CP was more posterior during the entire movement cycle. The BCR-TKA group showed higher tibial migration. No differences were found for the clinical and functional outcomes. Conclusion. The BCR-TKA shows a different kinematic pattern in early flexion/late extension compared to the CR-TKA. The difference between both implants is mostly visible in the flexion phase in which the anterior cruciate ligament is effective; however, both designs fail to fully replicate the motion of a natural knee. The higher migration of the BCR-TKA was concerning and highlights the importance of longer follow-up. Cite this article: Bone Joint J 2023;105-B(1):35–46

Objectives. Our aim was to assess the use of intra-operative fluoroscopy in the assessment of the position of the tibial tunnel during reconstruction of the anterior cruciate ligament (ACL). Methods. Between January and June 2009 a total of 31 arthroscopic hamstring ACL reconstructions were performed. Intra-operative fluoroscopy was introduced (when available) to verify the position of the guidewire before tunnel reaming. It was only available for use in 20 cases, due to other demands on the radiology department. The tourniquet times were compared between the two groups and all cases where radiological images lead to re-positioning of the guide wire were recorded. The secondary outcome involved assessing the tibial interference screw position measured on post-operative radiographs and comparing with the known tunnel position as shown on intra-operative fluoroscopic images. Results. Of the 20 patients treated with fluoroscopy, the imaging led to repositioning of the tibial guide wire before reaming in three (15%). The mean tourniquet time with intra-operative fluoroscopy was 56 minutes (44 to 70) compared with 51 minutes (42 to 67) for the operations performed without. Six patients (30%) had post-operative screw positions that were > 5% more posterior than the known position of the tibial tunnel. Conclusion. Intra-operative fluoroscopy can be effectively used to improve the accuracy of tibial tunnel positions with minimal increase in tourniquet time. This study also demonstrates the potential inaccuracy associated with plain radiological assessment of tunnel position

Aims. Modern total knee arthroplasty (TKA) prostheses are designed to restore near normal kinematics including high flexion. Kneeling is a high flexion, kinematically demanding activity after TKA. The debate about design choice has not yet been informed by six-degrees-of-freedom in vivo kinematics. This prospective randomized clinical trial compared kneeling kinematics in three TKA designs. Methods. In total, 68 patients were randomized to either a posterior stabilized (PS-FB), cruciate-retaining (CR-FB), or rotating platform (CR-RP) design. Of these patients, 64 completed a minimum one year follow-up. Patients completed full-flexion kneeling while being imaged using single-plane fluoroscopy. Kinematics were calculated by registering the 3D implant models onto 2D-dynamic fluoroscopic images and exported for analysis. Results. CR-FB designs had significantly lower maximal flexion (mean 116° (SD 2.1°)) compared to CR-RP (123° (SD 1.6°)) and PS-FB (125° (SD 2.1°)). The PS-FB design displayed a more posteriorly positioned femur throughout flexion. Furthermore, the CR-RP femur was more externally rotated throughout kneeling. Finally, individual patient kinematics showed high degrees of variability within all designs. Conclusion. The increased maximal flexion found in the PS-FB and CR-RP designs were likely achieved in different ways. The PS-FB design uses a cam-post to hold the femur more posteriorly preventing posterior impingement. The external rotation within the CR-RP design was surprising and hasn’t previously been reported. It is likely due to the polyethylene bearing being decoupled from flexion. The findings of this study provide insights into the function of different knee arthroplasty designs in the context during deep kneeling and provide clinicians with a more kinematically informed choice for implant selection and may allow improved management of patients' functional expectations. Cite this article: Bone Joint J 2021;103-B(1):105–112

Aims. The removal of the cruciate ligaments in total knee arthroplasty (TKA) has been suggested as a potential contributing factor to patient dissatisfaction, due to alteration of the in vivo biomechanics of the knee. Bicruciate retaining (BCR) TKA allows the preservation of the cruciate ligaments, thus offering the potential to reproduce healthy kinematics. The aim of this study was to compare in vivo kinematics between the operated and contralateral knee in patients who have undergone TKA with a contemporary BCR design. Methods. A total of 29 patients who underwent unilateral BCR TKA were evaluated during single-leg deep lunges and sit-to-stand tests using a validated computer tomography and fluoroscopic imaging system. In vivo six-degrees of freedom (6DOF) kinematics were compared between the BCR TKA and the contralateral knee. Results. During single-leg deep lunge, BCR TKAs showed significantly less mean posterior femoral translation (13 mm; standard deviation (SD) 4) during terminal flexion, compared with the contralateral knee (16.6 mm, SD 3.7; p = 0.001). Similarly, BCR TKAs showed significantly less mean femoral rollback (11.6 mm (SD 4.5) vs 14.4 mm (SD 4.6); p < 0.043) during sit-to-stand. BCR TKAs showed significantly reduced internal rotation during many parts of the strenuous flexion activities particularly during high-flexion lunge (4° (SD 5.6°) vs 6.5° (SD 6.1°); p = 0.051) and during sit-to-stand (4.5° (SD 6°) vs 6.9° (SD 6.3°); p = 0.048). Conclusion. The contemporary design of BCR TKA showed asymmetrical flexion-extension and internal-external rotation, suggesting that the kinematics are not entirely reproduced during strenuous activities. Future studies are required to establish the importance of patient factors, component orientation and design, in optimizing kinematics in patients who undergo BCR TKA. Cite this article: Bone Joint J 2020;102-B(6 Supple A):59–65

Aims

This study aimed to analyze kinematics and kinetics of the tibiofemoral joint in healthy subjects with valgus, neutral, and varus limb alignment throughout multiple gait activities using dynamic videofluoroscopy.

Objectives. The medially spherical GMK Sphere (Medacta International AG, Castel San Pietro, Switzerland) total knee arthroplasty (TKA) was previously shown to accommodate lateral rollback while pivoting around a stable medial compartment, aiming to replicate native knee kinematics in which some coronal laxity, especially laterally, is also present. We assess coronal plane kinematics of the GMK Sphere and explore the occurrence and pattern of articular separation during static and dynamic activities. Methods. Using pulsed fluoroscopy and image matching, the coronal kinematics and articular surface separation of 16 well-functioning TKAs were studied during weight-bearing and non-weight-bearing, static, and dynamic activities. The closest distances between the modelled articular surfaces were examined with respect to knee position, and proportions of joint poses exhibiting separation were computed. Results. Overall, 1717 joint poses were analyzed. At a 1.0 mm detection threshold, 37 instances of surface separation were observed in the lateral compartment and four medially (p < 0.001). Separation was activity-dependent, both laterally and medially (p < 0.001), occurring more commonly during static deep flexion in the lateral compartment, and during static rotation in the medial compartment. Lateral separation occurred more frequently than medial during kneeling (7/14 lateral vs 1/14 medial; p = 0.031) and stepping (20/1022 lateral vs 0/1022 medial; p < 0.001). Separation varied significantly between individuals during dynamic activities. Conclusion. No consistent association between closest distances of the articular surfaces and knee position was found during any activity. Lift-off was infrequent and depended on the activity performed and the individual knee. Lateral separation was consistent with the design rationale. Medial lift-off was rare and mostly in non-weight-bearing activities. Cite this article: S. Key, G. Scott, J. G. Stammers, M. A. R. Freeman†, V. Pinskerova, R. E. Field, J. Skinner, S. A. Banks. Does lateral lift-off occur in static and dynamic activity in a medially spherical total knee arthroplasty? A pulsed-fluoroscopic investigation. Bone Joint Res 2019;8:207–215. DOI: 10.1302/2046-3758.85.BJR-2018-0237.R1

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The goal was to evaluate tibiofemoral knee joint kinematics during stair descent, by simulating the full stair descent motion in vitro. The knee joint kinematics were evaluated for two types of knee implants: bi-cruciate retaining and bi-cruciate stabilized. It was hypothesized that the bi-cruciate retaining implant better approximates native kinematics.

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We aimed to assess the reliability and validity of OpenPose, a posture estimation algorithm, for measurement of knee range of motion after total knee arthroplasty (TKA), in comparison to radiography and goniometry.

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The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

Objectives. Throughout the 20th Century, it has been postulated that the knee moves on the basis of a four-bar link mechanism composed of the cruciate ligaments, the femur and the tibia. As a consequence, the femur has been thought to roll back with flexion, and total knee arthroplasty (TKA) prostheses have been designed on this basis. Recent work, however, has proposed that at a position of between 0° and 120° the medial femoral condyle does not move anteroposteriorly whereas the lateral femoral condyle tends, but is not obliged, to roll back – a combination of movements which equates to tibial internal/ femoral external rotation with flexion. The aim of this paper was to assess if the articular geometry of the GMK Sphere TKA could recreate the natural knee movements in situ/in vivo. Methods. The pattern of knee movement was studied in 15 patients (six male: nine female; one male with bilateral TKAs) with 16 GMK Sphere implants, at a mean age of 66 years (53 to 76) with a mean BMI of 30 kg/m. 2. (20 to 35). The motions of all 16 knees were observed using pulsed fluoroscopy during a number of weight-bearing and non-weight-bearing static and dynamic activities. Results. During maximally flexed kneeling and lunging activities, the mean tibial internal rotation was 8° (standard deviation (. sd. ) 6). At a mean 112° flexion (. sd. 16) during lunging, the medial and lateral condyles were a mean of 2 mm (. sd. 3) and 8 mm (. sd. 4) posterior to a transverse line passing through the centre of the medial tibial concavity. With a mean flexion of 117° (. sd. 14) during kneeling, the medial and lateral condyles were a mean of 1 mm (. sd. 4) anterior and 6 mm (. sd. 4) posterior to the same line. During dynamic stair and pivoting activities, there was a mean anteroposterior translation of 0 mm to 2 mm of the medial femoral condyle. Backward lateral condylar translation occurred and was linearly related to tibial rotation. Conclusion. The GMK Sphere TKA in our study group shows movements similar in pattern, although reduced in magnitude, to those in recent reports relating to normal knees during several activities. Specifically, little or no translation of the medial femoral condyle was observed during flexion, but there was posterior roll-back of the lateral femoral condyle, equating to tibiofemoral rotation. We conclude that the GMK Sphere is anteroposteriorly stable medially and permits rotation about the medial compartment. Cite this article: Professor G. Scott. Can a total knee arthroplasty be both rotationally unconstrained and anteroposteriorly stabilised?: A pulsed fluoroscopic investigation. Bone Joint Res 2016;5:80–86. DOI: 10.1302/2046-3758.53.2000621

Aims

Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure.

Abnormal sagittal kinematics after total knee replacement (TKR) can adversely affect functional outcome. Two important determinants of knee kinematics are component geometry and the presence or absence of a posterior-stabilising mechanism (cam-post). We investigated the influence of these variables by comparing the kinematics of a TKR with a polyradial femur with a single radius design, both with and without a cam-post mechanism. We assessed 55 patients, subdivided into four groups, who had undergone a TKR one year earlier by using an established fluoroscopy protocol in order to examine their kinematics in vivo. The kinematic profile was obtained by measuring the patellar tendon angle through the functional knee flexion range (0° to 90°) and the results compared with 14 normal knees. All designs of TKR had abnormal sagittal kinematics compared with the normal knee. There was a significant (p < 0.05) difference between those of the two TKRs near to full extension. The presence of the cam-post mechanism did not influence the kinematics for either TKR design. These differences suggest that surface geometry is a stronger determinant of kinematics than the presence or absence of a cam-post mechanism for these two designs. This may be because the cam-post mechanism is ineffective

Aims

Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release.

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Ideal component sizing may be difficult to achieve in unicompartmental knee arthroplasty (UKA). Anatomical variants, incremental implant size, and a reduced surgical exposure may lead to over- or under-sizing of the components. The purpose of this study was to compare the accuracy of UKA sizing with robotic-assisted techniques versus a conventional surgical technique.

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The purpose of this study was to compare the radiological outcomes of manual versus robotic-assisted medial unicompartmental knee arthroplasty (UKA).

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This study aims to investigate the effects of posterior tibial slope (PTS) on knee kinematics involved in the post-cam mechanism in bi-cruciate stabilized (BCS) total knee arthroplasty (TKA) using computer simulation.

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The primary objective of this study was to compare migration of the cemented ATTUNE fixed bearing cruciate retaining tibial component with the cemented Press-Fit Condylar (PFC)-sigma fixed bearing cruciate retaining tibial component. The secondary objectives included comparing clinical and radiological outcomes and Patient Reported Outcome Measures (PROMs).

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A retrospective longitudinal study was conducted to compare directly volumetric wear of retrieved polyethylene inserts to predicted volumetric wear modelled from individual gait mechanics of total knee arthroplasty (TKA) patients.

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There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome.

Objectives

Unicompartmental knee arthroplasty (UKA) is one surgical option for treating symptomatic medial osteoarthritis. Clinical studies have shown the functional benefits of UKA; however, the optimal alignment of the tibial component is still debated. The purpose of this study was to evaluate the effects of tibial coronal and sagittal plane alignment in UKA on knee kinematics and cruciate ligament tension, using a musculoskeletal computer simulation.