(iii) Biomechanics of the knee

and TKR
R Shenoy
PS Pastides
D Nathwani
Abstract
The principal aim of a total knee replacement (TKR) is to restore painless
movements of the knee joint. Osteoarthritis, along with other pathologies
that damage the articular surface of the knee, results in painful limitation
of knee movement and alteration of shape and alignment of the joint.
Restoration of the functional anatomy of the knee, including alignment,
soft tissue balancing and restoration of the joint line, are integral to
improving function. Factors that ensure long-term survival of the replaced
knee have to be addressed while performing this procedure. Biome-
chanics of the knee and its restoration are key to improving both function
and survival of a total knee replacement. Screw home movement in termi-
nal extension and femoral roll back in exion are unique to the knee joint.
The patella improves extensor function by increasing its lever arm.
Implant designs available include femoral components of xed or multi-
ple radii, high exion knee replacements, posterior cruciate retaining or
substituting designs and xed or mobile tibial inserts. Computer naviga-
tion has been used to achieve accurate bone alignment and soft tissue
balancing. Further research on these advances is essential to dene
their role in improving the results of TKR.
Keywords biomechanics; osteoarthritis; patellofemoral joint; tibiofe-
moral joint; total knee replacement
Introduction
The knee joint is the largest joint in the human body and allows a
complex set of movements. While mainly functioning as a hinge
joint, it also allows pivoting and anteroposterior gliding move-
ments. This is a function of the anatomy of the articular surfaces
and the soft tissues around the joint, including ligaments,
menisci and musculotendinous structures. Alignment of the joint
is determined by the anatomical structures comprising the knee
joint, which control the relative movement of femoral, tibial and
patellar surfaces against each other. Forces transmitted across
the articulating surfaces are determined by a combination of the
alignment, movement and integrity of anatomical structures.
Tibiofemoral biomechanics
Movements
In full extension the knee is locked by the screw-home mecha-
nism, which allows maintenance of this position with minimal
energy expenditure. The knee allows up to 160 degrees of exion
from up to ve degrees of hyperextension. The amount of exion
required varies from about 60 degrees needed for normal
walking, 80 degrees to climb stairs, 90 degrees to descend down
stairs, 115 degrees to sit down on a toilet seat and up to 130
degrees to squat. This exion is a combination of rolling and
gliding. In early exion, up to 20 degrees, there occurs a rolling
movement that translates the point of tibiofemoral contact pos-
teriorly. With further exion there is a gliding movement, with a
greater posterior translation of the lateral tibiofemoral contact
point in relation to the medial contact point. Along with exion
and extension the knee allows 25e30 degrees of rotation,
6eeight degrees of valgus and varus in extension, 5e10 mm of
anteroposterior translation and 1e2 mm of mediolateral trans-
lation. The articular cartilage and the menisci also allow 2e5 mm
of joint compression. The knee joint can hence be regarded as a
joint that allows movement with six degrees of freedom
(Figure 1).
Asymmetry of the femoral articular surface and their geome-
try, tension in the capsuloligamentous structures and the action
Figure 1 Diagram showing movements of the knee with six degrees of
freedom.
R Shenoy MSOrth DNBOrth MRCS MDRes Senior Trauma Fellow, Department
of Trauma and Orthopaedics, Imperial College Healthcare Trust,
London, UK. Conicts of interest: none.
PS Pastides MRCS MSc (Orth Eng) Specialty Registrar, Department of
Trauma and Orthopaedics, Imperial College Healthcare Trust, London,
UK. Conicts of interest: none.
D Nathwani MBChB MSc FRCS (Tr&Orth) Consultant, Department of Trauma
and Orthopaedics, Imperial College Healthcare Trust, London, UK.
Conicts of interest: none.
MINI-SYMPOSIUM: THE KNEE
ORTHOPAEDICS AND TRAUMA 27:6 364 2013 Elsevier Ltd. All rights reserved.
of the muscles around the knee joint together contribute to the
complex movement of screw-home of the femur in terminal
extension and femoral roll back in exion. The larger area of the
articulating medial condyle permits anterior translation and
external rotation of the tibia in relation to the femur in extension.
The shape of the articular surface including a larger radius of
lateral femoral condyle produces a net internal rotation of the
tibia over the femur in exion. The four-bar link mechanism
produced by the two cruciate ligaments along with the femur and
tibia contribute to posterior femoral roll back by causing a pos-
terior translation of the instantaneous centre of rotation of knee
joint with increasing exion, preventing soft tissue impingement
posteriorly while also decreasing patellar load (Figure 2a and b).
A change in geometry of the articulating surfaces or a change in
any of the components of the linkage system will affect these
movements. Knee replacements with increased congruency of
the articulating surface prevent posterior roll back and increase
stresses in the posterior cruciate ligament if this ligament is
retained.
Alignment
Restoration of adequate function and good long-term prosthesis
survivorship following a total knee replacement (TKR) necessi-
tate consideration of the forces acting on the knee joint. These
are determined by a combination of the alignment of the com-
ponents and by the musculotendinous structures. The axes used
for reference include the mechanical axis and the anatomic axis
1
(Figure 3).
The mechanical axis of the lower limb is a straight line drawn
from the centre of the femoral head to the centre of the ankle.
The femoral mechanical axis is a straight line drawn from the
centre of the femoral head to the centre of the intercondylar re-
gion. The mechanical axis of the tibia is a straight line drawn
from the centre of the tibial plateau to the centre of the ankle
joint. A standing Maquet view is used to demonstrate these lines.
In the coronal and sagittal planes the mechanical axis of the limb
overlies that of the femur and tibia in a mechanically neutral
limb. The mechanical axis of the lower limb is not parallel to the
vertical line drawn from the symphysis pubis; it makes an angle
of three degrees with this vertical line. The joint line, which is
perpendicular to the vertical line, is in three degrees of varus in
relation to the mechanical axis.
The anatomical axis of the femur and tibia are straight lines
drawn along their medullary canals respectively. In the tibia, the
anatomical and mechanical axis overlie each other, whereas in
the femur the anatomical axis makes an angle of 5e7 degrees
with the mechanical axis in the coronal plane, depending on the
height of the individual and the pelvic width. Consequently, in
the coronal plane the anatomical axis of the femur makes an
angle of 8e10 degrees with the vertical. While performing a total
knee replacement, the anatomical axis can be identied either by
using intramedullary rods or by extramedullary guides. De-
formities of the bone can affect accurate measurement using
intramedullary techniques, and conditions such as obesity can
make it difcult to locate bony landmarks while using extra-
medullary guides.
Figure 2 (a) The two cruciate ligaments guide femoral roll back in exion. PCL: posterior cruciate ligament, ACL: anterior cruciate ligament. (b) four-bar
linkage formed by the xed distance between femoral attachments of the cruciate ligaments (a, F), the anterior cruciate ligament (b, ACL), the posterior
cruciate ligament (c, PCL), the tibial attachments of the cruciate ligaments (d, T). The instantaneous centre of rotation moves posteriorly with increasing
exion allowing posterior roll back.
MINI-SYMPOSIUM: THE KNEE
ORTHOPAEDICS AND TRAUMA 27:6 365 2013 Elsevier Ltd. All rights reserved.
In the sagittal plane, the articular surface of the tibia has a
posterior slope. This is commonly measured by the angle be-
tween the anatomical axis of the tibia and a line drawn along the
tibial plateau. This slope is said to be six to nine degrees but is
reduced by the wedge-shaped meniscus. In a cruciate retaining
prosthesis it is essential to reproduce this slope to ensure satis-
factory roll back of the femur. A lesser slope is used in posteriorly
stabilized implants to prevent excessive anterior translation of
the tibia.
Another key alignment to be considered is the rotational
alignment. This affects tibiofemoral and patellofemoral kine-
matics. It also affects exion alignment and stability. Reference
lines used to measure femoral rotation include the Whiteside
line, the transepicondylar line and the posterior condylar line of
femur (Figure 4). The transepicondylar line is clearly dened by
anatomic landmarks and is a mechanical axis around which
femoral rotation occurs. It is perpendicular to the mechanical
axis in both exion and extension. Since the epicondyles serve as
attachment sites for the collateral ligaments, this line is also an
important reference for soft tissue balancing. The Whiteside line,
drawn from the deepest part of the trochlear grove anteriorly to
the centre of the intercondylar notch posteriorly, is easier to
identify and is almost perpendicular to the transepicondylar axis.
The posterior condylar line of the femur can also be used as a
reference line and makes an angle of three degrees with the
transepicondylar line. In a exed knee this neutralizes the three
degree varus of the tibial articular surface in the coronal plane,
enabling the transepicondylar axis to remain parallel to the tibial
articular surface. However, this line can be easily affected by
arthritic changes and condylar hypoplasia, and is less reliable.
Rotational alignment of the tibia is measured by drawing a
medial to lateral line connecting the widest point of the tibial
articular surface. An anteroposterior axis perpendicular to this
line is used for reference. Commonly, the tibial component is
aligned along the medial third of the insertion of the patellar
tendon, as the tibial tuberosity in a normal knee is offset laterally
by 1 cm from the trochlear grove. The posterior condylar line of
the tibia and the transmalleolar axis are some of the other
anatomical references used for assessing rotational alignment of
the tibia.
Joint reaction force
The tibiofemoral joint is subject to forces due to a combination of
transmission of the body weight across the joint and the
contraction of muscles around the knee. Muscle forces can
contribute to up to 80% of the maximum bone-on-bone force
during downhill walking and 70% of maximum bone-on-bone
force during level walking. Estimates of tibiofemoral bone-on-
bone forces have been reported to be up to four times the body
weight during level walking and more than eight times the body
weight during downhill walking.
2
In a normal knee this
compressive force is resisted by the joint reaction force. The
stresses experienced by the articular surface depend on the
contact area. The presence of the menisci makes the joint more
congruent, with the reported contact area ranging from 765 mm
2
to 1150 mm
2
in a normal knee. The circumferential arrangements
of bres within the menisci generate hoop stresses and help
dissipate the compressive forces. The contact area can decrease
by up to 20% following a partial meniscectomy and by 50e70%
Figure 3 Anatomical and mechanical axis of the lower limb (Redrawn from
Moreland JR, Hanker GJ: Lower-extremity axial alignment in males. In Dorr
LD, ed: The knee: papers of the First Scientic Meeting of the Knee So-
ciety, Baltimore, 1984, University Park Press.).
Figure 4 Reference axis used for rotational alignment of the femoral
components while performing a total knee replacement. The transepi-
condylar axis is in three degrees of external rotation with reference to the
posterior condylar axis. AP: anteroposterior; TEA: transepicondylar axis;
PCA: posterior condylar axis.
MINI-SYMPOSIUM: THE KNEE
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following a total meniscectomy.
3e5
The resulting increase in
contact stresses accelerates progression of degenerative arthritis
in the tibiofemoral joint following a meniscectomy. This effect is
more pronounced over the lateral compartment as the lateral
tibial articular surface is slightly convex and less congruent with
the femoral articular surface.
The articulating surface in a knee replacement is metal on
ultrahigh molecular weight polyethylene (UHMWP), which has a
yield point of approximately 20Mpa. The contact area in a knee
replacement depends upon the design of prosthesis, with
congruent tibiofemoral articulating surfaces decreasing the
stresses across the joint. To allow for femoral roll back in knee
replacements where the PCL is preserved, the tibial joint surface
has to be relatively at. This sagittal plane non-conformity gen-
erates higher contact stresses. Dishing the articular surfaces in
both the sagittal and coronal planes increases the contact area
and avoids areas of high contacts stresses.
6
A minimum thick-
ness of 8 mm polyethylene is recommended to prevent high
contact stresses and excessive wear.
Patellofemoral biomechanics
The patella is a sesamoid bone within the quadriceps tendon that
increases the lever arm of the extensor mechanism, resulting in
an improvement in quadriceps efciency. The quadriceps tendon
and the patellar tendon are inserted along the anterior surface of
the patella. The thickness of the patella displaces the force vec-
tors of these two tendons anterior to the centre of rotation of the
knee joint. Patellectomy decreases extensor forces by up to 30%.
The patellofemoral joint is subject to a compressive force that is a
summation of the vectors of quadriceps and patellar tendon
forces (Figure 5). Flexion of the knee increases this summated
force. The joint reaction force that opposes the backward
compression of the patella increases with knee exion and can
reach three times the body weight during stair ascent and
descent. With deep exion, as in squatting, this can reach seven
to eight times body weight.
7
The thick patellar cartilage resists
this force in a normal knee, while it is the polythene in a patel-
lofemoral replacement that is subjected to this force. Alignment
and uniform tracking of the patella in the trochlear notch pre-
vents excessive peak forces across the patellar facets. Capsu-
loligamentous structures attached to the patella help maintain
the stability and control movement of the patella, which can
move up to 7 cm in the craniocaudal direction within the
trochlear grove. As the knee moves from extension to exion, the
part of the patella articulating with the trochlea moves superi-
orly, with the quadriceps tendon making contact with the
trochlea in 120 degrees of exion.
8
The Q angle, which is the angle of intersection of the quad-
riceps force vector (commonly marked by a line from the anterior
superior iliac spine to the centre of the patella) with the line
drawn along the centre of the patellar tendon (a line drawn from
the centre of the patella to the tibial tuberosity) also inuences
patellofemoral stability. There is a laterally directed force vector
that is greater in limbs with a larger Q angle. This is resisted by
the medial capsuloligamentous structures; mainly the medial
patellofemoral ligament and the vastus medialis obliquus. The
mean Q angle in females is 15.8 4.5 degrees and that for men is
11.2 3 degrees.
9
The Q angle is increased in a valgus knee and
in cases where the femoral and tibial components are medialized
or internally rotated. There is an increase in pressure over the
lateral patellar facet, with a tendency for lateral subluxation of
the patella in such knees.
Total knee replacement e implant design considerations
Geometry of the femoral component
Contemporary designs of the femoral component of a TKR were
based on the concept of a polycentric pathway followed by the
centre of radius of curvature of the femoral condyles. Studies
showed that the tibiofemoral articulation initially rotated axially
from 0 to 10 degrees followed by rocking from 10 to 20 degrees
and gliding from 20 degrees to full exion, allowing femoral roll
back. The instantaneous centre of rotation of the joint was
believed to follow a spiral pathway and femoral components
incorporated this in their design, with multiple radii of curva-
ture.
10
With this design the cruciate and collateral ligaments
were preserved to maintain joint alignment and partially absorb
stresses while the implant articular surface was subjected to
mainly compression loading. This anatomical concept of knee
replacement evolved to produce a duopatellar design, where the
two femoral condyles were replaced along with an anterior
ange for the patella and a patellar button.
11
The total condylar prosthesis was an attempt to simplify knee
biomechanics by resecting the cruciates. In this design the femoral
condylar surface has a posterior decreasing radius of curvature.
12
Most femoral components of a total knee replacement followed
this concept of variable exion extension axis. This concept has
been challenged by other authors. Using magnetic resonance im-
aging and cadaveric studies it has been shown that the exione
extension axis is constant and passes from anterosuperior on the
medial side to posteroinferior on the lateral side, closely approxi-
mating the transepicondylar axis passing through the origins of the
Figure 5 The patellofemoral joint is subjected to a compressive force that
is the resultant summative force of the vectors of the patellar tendon and
the quadriceps tendon forces.
MINI-SYMPOSIUM: THE KNEE
ORTHOPAEDICS AND TRAUMA 27:6 367 2013 Elsevier Ltd. All rights reserved.
collateral ligaments, and superior to the crossing point of the cru-
ciates.
13,14
This produces the valgus and external rotation move-
ment seen with extension of the knee joint. The longitudinal
rotation axis is not perpendicular to the exioneextension axis but
is anterior and passes through the medial compartment. The single
axis total knee replacement was designed based on this concept of a
single exion extension axis. The variable exion axis caused by a
decrease in the radius of curvature in exion was thought to result
in mid-exion instability and altered patellofemoral kinematics.
The single radius design, however, lengthens the quadriceps
moment arm, with a resulting decrease in quadriceps force and
hence joint reaction force.
Biomechanical studies have been reported to show less
eccentric knee extensor muscle activation and greater medio-
lateral stability during the stand-to-sit movement with the single
radius design. Patients with multiple radius design knees have
been shown to demonstrated compensatory adaptations, with
lengthening of performance times, increased trunk exion
displacement and velocity, and greater knee extensor electro-
myography readings compared to patients with a single radius
design. A greater relative hamstring co-activation was needed in
the multiple radius knees to increase joint stability. More patients
with multiple radius knees demonstrated an initial knee abduc-
tion displacement. The single radius design patients also
demonstrated greater peak anteroposterior ground reaction force,
higher anteroposterior ground reaction impulse and reduced
vastus lateralis and semitendinosus EMG during the forward-
thrust phase of a sit-to-stand movement. Based on these nd-
ings, the authors concluded that a single radius design provided
functional benets to the patient.
15e17
In a randomized trial, power output was assessed using a Leg
Extensor Power Rig, pre-operatively and at 6, 26 and 52 weeks
post-operatively in patients with 101 Triathlon single radius and
82 Kinemax multiple radius implants. Power output was signif-
icantly greater at all post-operative assessments in the single
radius compared to the multi radius group. The authors
concluded that this supported the hypothesis of single radius
design total knee replacements having enhanced recovery and
better function.
18
An investigation into the kinematics of the
natural knee, comparing this with single radius and multiple
radius total knee replacements in vitro, did not nd evidence of
mid range instability in any knees, suggesting that this may not
be related to any specic implant design.
19
High exion total knee replacement
Functional outcome following a total knee replacement is inu-
enced by the range of exion, with traditional knee replacements
rarely achieving exion more than 115 degrees. Studies have
shown that the most signicant factor inuencing post-operative
exion was the pre-operative range of exion.
20,21
In an effort to
improve post-operative exion, changes have been made to the
design of the total knee replacement implant, which include
modication in tibial and femoral components to accommodate
and reduce pressure over the extensor mechanism, improve
femoral roll back, extension of the posterior aspect of femoral
condyles to allow deep exion and reduction in posterior femoral
condylar radii.
22,23
This concept of design modication to improve function
showed encouraging results in early studies. A systematic review
of published studies on high exion total knee replacements
failed to show sufcient evidence of improved function or range
of movements with this design.
22
A recent review of published
results of prospective, randomized clinical trials that compared a
standard posterior-stabilized TKR with a high exion posterior-
stabilized TKR design did not reveal any signicant difference
between the two designs in clinical exion or range of motion.
The authors recommended weighing the downsides of these
designs, such as increased cost, increased bone resection, and
early femoral loosening, against the potential long-term
improvement in polyethylene wear due to increased conformity
in high exion.
24
Ligament retaining/substituting designs
The posterior cruciate ligament (PCL) is considered to play a vital
role in posterior roll back of the femur in exion. As it is in
tension with exion, it draws back the femoral condyles. The
orientation of the bres with its attachment to the medial femoral
condyle leads to a rotational movement along the vertical axis,
resulting in the lateral femoral condyle being drawn back more
posteriorly. Retaining the PCL helps preserve this movement as
long as its function is preserved by adequately balancing the
knee in exion and extension. As this ligament is normally under
tension in exion and lax in extension, this relationship needs to
be maintained while performing bone cuts and choosing the size
of the polythene insert. The tibial surface has to be relatively at
when the PCL is retained, to allow femoral roll back and prevent
excessive tension in the PCL. The PCL in some cases may be
incompetent due to injury or degeneration. Surgeons may also
choose to sacrice the PCL while performing a knee replacement
in cases where exion is tight, to prevent excessive stresses and
wear of the polythene insert. There are prostheses that have been
designed to substitute the function of the PCL by means of a
central cam on the femoral implant, which is pushed back by the
central post on the polythene insert (Figure 6). This posteriorly
stabilized (cruciate substituting) design helps reproduce femoral
roll back. The centre post also provides anteroposterior stability
in cases where there is a weak extensor mechanism. Further-
more, this design can have more congruent articulating surfaces,
which helps decrease stress. One of the potential draw backs
Figure 6 The cam on the femoral component moves on the central post on
the polythene tibial insert, resulting in a posterior roll back of the femur
with exion in a cruciate substituting total knee replacement.
MINI-SYMPOSIUM: THE KNEE
ORTHOPAEDICS AND TRAUMA 27:6 368 2013 Elsevier Ltd. All rights reserved.
with this design is the potential for the cam to jump in front of
the central peg with hyperextension of the knee or if the knee is
excessively loose in exion, and cause a dislocation of the knee.
Scar tissue impingement in the central box of the femoral
component, resulting in a clunk, and wear of the polythene of the
tibial post are other disadvantages with the cruciate sacricing
design.
A review comparing retention or sacrice of the PCL in a TKR
with or without use of a PCL substituting implant did not nd
sufcient evidence to support decision-making. The authors
recommended interpreting these results with caution as the
methodological quality of the studies was highly variable. As the
normal conguration and tension of the PCL need to be repro-
duced accurately, performing a cruciate retaining knee replace-
ment can be difcult.
25
Other designs available to preserve or reproduce the complex
movements of a normal knee include the ACLePCL retaining
implant and the medial or lateral pivot implant. The ACLePCL
retaining knee is designed to retain stability and proprioception of
the knee while the medial or lateral pivot design aims to restore the
normal axial rotation that occurs with knee exion and extension.
In a prospective randomized study of 440 patients undergoing
staged bilateral total knee replacement, the prosthesis used
included anterioreposterior cruciate-retaining (ACLePCL), pos-
terior cruciate-retaining (PCL), Medial Pivot (MP), posterior
cruciate-substituting (PS) and mobile bearing (MB). Patients
received random pairings of the different designs to allow for
comparison. At 2-year evaluation, 89.1% preferred the ACLePCL
to the PS and 76.2%preferred the MP to the PS. The ACLePCL and
the MP were preferred equally. Range of motion, pain relief,
alignment and stability did not vary signicantly by prosthesis
used. In summary, patients with bilateral total knee arthroplasties
preferred retention of both cruciates with use of the ACLePCL
prosthesis or substituting with an MP prosthesis. The authors,
however, cautioned that this study did not address complications
or long-term survival of the implants.
26
Fixed or mobile bearing total knee replacement
Reproducing the movements of a knee with a TKR necessitates a
design that allows movements in all three planes. To prevent
excessive stresses at the bone-implant interface, mobile bearing
knee replacements were introduced (Figure 7). These designs
allow anteroposterior translation or rotation or both at the tibial
tray-insert interface. With this design it is possible to have a
highly congruent articular surface that also allows gliding and
rotation. There is also a reduction in stress, with reduced wear of
the articulating surface. The mobile bearing design allows self-
correction of mild surgical malalignment.
Studies both in vivo and in vitro have failed to demonstrate a
signicant advantage of the mobile bearing knee in comparison
with xed bearing knees. Femoral roll back and axial rotation do
not differ signicantly between the two designs. Mobile bearing
knees can produce smaller particulate debris and more granular
debris, subjecting these knees to a higher risk of osteolysis.
27
Late
rotation dislocation is another reported complication of a mobile
bearing knee replacement.
28
Clinical studies comparing xed
bearing and mobile knees have not shown a difference in range of
motion, knee scores or complication rates although the study by
Ball et al showed signicantly better stair climbing scores.
29e31
The role of computer navigation
Achieving correct alignment and adequate soft tissue balancing
ensures improved function and potentially longer survival of the
implant. The use of jigs intra-operatively guides correct bony
resections while intra-operative assessment of soft tissue tension
guides soft tissue balancing. Even in experienced hands, 10% of
TKRs have been shown to have greater than three degrees of
error in the mechanical axis.
32
Precise and reproducible bone
resection and ligament balancing is possible with the help of
computer navigation. These navigation systems can be CT based,
uoroscopy based or imageless.
In a meta-analysis, Mason et al compared mechanical axis
alignment between computer assisted and conventional knee
replacements, and reported malalignment of greater than three
degrees in 9% of computer assisted knees versus 31.8% of
conventional TKRs.
33
Other authors have failed to observe ad-
vantages with navigation. A meta-analysis by Bauwens et al re-
ported an increase in operative time of 23% with computer
navigation with no signicant improvement in the accuracy of
the mechanical axis.
34
Barrett et al, in a multi-centre prospective
randomized trial, reported a signicant improvement in coronal
tibial alignment following computer navigation, but this was
associated with a signicant increase in operative time.
35
A
recent review has concluded that navigation helps reduce out-
liers in radiographic coronal plane alignment. There is limited
evidence of improvement in any other parameters or function. As
there is a signicant increase in operative time and costs, the
authors concluded that navigation does not have any proven
clinical benet.
36
Conclusion
The knee allows motion with six degrees of freedom. The bony
anatomy and the capsuloligamentous structures supporting the
joint guide this complex set of movements, which include screw
Figure 7 Parts of a mobile bearing total knee replacement.
MINI-SYMPOSIUM: THE KNEE
ORTHOPAEDICS AND TRAUMA 27:6 369 2013 Elsevier Ltd. All rights reserved.
home movement in terminal extension and femoral roll back in
exion. Alignment of the femur in all three planes along with
achieving soft tissue balancing are integral to restoring function
following a total knee arthroplasty. The patella increases the
quadriceps lever arm. Joint reaction forces across the patellofe-
moral and tibiofemoral articulations have to be considered while
choosing the implant and aligning them during a TKR. The
design of TKR prostheses has evolved, with the aim of improving
function and survival of the replaced joint. The changes include
modication of the shape of femoral components, PCL retaining
or substituting designs, designs to allow high exion, xed or
mobile tibial inserts and the use of computer guided navigation
to improve alignment and balancing. While many of these newer
designs aim to replicate the biomechanics of the normal knee and
have potential theoretical advantages, further studies are needed
to assess fully their actual clinical benets. A
REFERENCES
1 Pickering S, Armstrong D. Focus on alignment in total knee
replacement. J Bone Joint Surg 2012; 1e3.
2 Kuster MS, Wood GA, Stachowiak GW, Gachter A. Joint load consid-
erations in total knee replacement. J Bone Joint Surg Br 1997; 79:
109e13.
3 Ahmed AM, Burke DL. In-vitro measurement of static pressure dis-
tribution in synovial joints e Part I: tibial surface of the knee.
J Biomech Eng 1983; 105: 216e25.
4 Baratz ME, Fu FH, Mengato R. Meniscal tears: the effect of
meniscectomy and of repair on intraarticular contact areas and
stress in the human knee. A preliminary report. Am J Sports Med
1986; 14: 270e5.
5 Ihn JC, Kim SJ, Park IH. In vitro study of contact area and pressure
distribution in the human knee after partial and total meniscectomy.
Int Orthop 1993; 17: 214e8.
6 Canale ST, Beaty JH, Campbell WCOo. Campbells operative ortho-
paedics. editorial assistance by Kay Daugherty and Linda Jones ; art
co-ordination by Barry Burns. In: Terry Canale S, Beatty James H, eds.
11th edn. St. Louis, Mo.; London: Mosby Elsevier, 2008.
7 Reilly DT, Martens M. Experimental analysis of the quadriceps muscle
force and patello-femoral joint reaction force for various activities.
Acta Orthop Scand 1972; 43: 126e37.
8 Hungerford DS, Barry M. Biomechanics of the patellofemoral joint.
Clin Orthop Relat Res 1979; 9e15.
9 Horton MG, Hall TL. Quadriceps femoris muscle angle: normal values
and relationships with gender and selected skeletal measures. Phys
Ther 1989; 69: 897e901.
10 Gunston FH. Polycentric knee arthroplasty. Prosthetic simulation of
normal knee movement. J Bone Joint Surg Br 1971; 53: 272e7.
11 Scott RD. Duopatellar total knee replacement: the Brigham experi-
ence. Orthop Clin North Am 1982; 13: 89e102.
12 Insall J, Ranawat CS, Scott WN, Walker P. Total condylar knee
replacement: preliminary report. Clin Orthop Relat Res 1976;
149e54.
13 Churchill DL, Incavo SJ, Johnson CC, Beynnon BD. The trans-
epicondylar axis approximates the optimal exion axis of the knee.
Clin Orthop Relat Res 1998; 111e8.
14 Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG. The axes
of rotation of the knee. Clin Orthop Relat Res 1993; 259e68.
15 Wang H, Simpson KJ, Chamnongkich S, Kinsey T, Mahoney OM.
A biomechanical comparison between the single-axis and multi-axis
total knee arthroplasty systems for the stand-to-sit movement. Clin
Biomech (Bristol, Avon) 2005; 20: 428e33.
16 Wang H, Simpson KJ, Chamnongkich S, Kinsey T, Mahoney OM.
Biomechanical inuence of TKA designs with varying radii on bilateral
TKA patients during sit-to-stand. Dyn Med 2008; 7: 12.
17 Wang H, Simpson KJ, Ferrara MS, Chamnongkich S, Kinsey T,
Mahoney OM. Biomechanical differences exhibited during sit-to-
stand between total knee arthroplasty designs of varying radii.
J Arthroplasty 2006; 21: 1193e9.
18 Hamilton DF, Gaston P, Simpson AHRW. Single radius of curvature
implant design enhances power output following total knee arthro-
plasty. J Bone Joint Surg Br 2012;(suppl 67); 94.
19 Stoddard JE, Deehan DJ, Bull AM, McCaskie AW, Amis AA. The kine-
matics and stability of single-radius versus multi-radius femoral
components related to mid-range instability after TKA. J Orthop Res
2013; 31: 53e8.
20 Anouchi YS, McShane M, Kelly Jr F, Elting J, Stiehl J. Range of motion
in total knee replacement. Clin Orthop Relat Res 1996; 87e92.
21 Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME. Predicting
range of motion after total knee arthroplasty. Clustering, log-linear
regression, and regression tree analysis. J Bone Joint Surg Am 2003;
85-A: 1278e85.
22 Murphy M, Journeaux S, Russell T. High-exion total knee arthro-
plasty: a systematic review. Int Orthop 2009; 33: 887e93.
23 Sultan PG, Most E, Schule S, Li G, Rubash HE. Optimizing exion after
total knee arthroplasty: advances in prosthetic design. Clin Orthop
Relat Res 2003; 167e73.
24 Hamilton WG, Sritulanondha S, Engh Jr CA. Results of prospective,
randomized clinical trials comparing standard and high-exion
posterior-stabilized TKA: a focused review. Orthopedics 2011; 34:
e500e3.
25 Jacobs WC, Clement DJ, Wymenga AB. Retention versus sacrice of
the posterior cruciate ligament in total knee replacement for treat-
ment of osteoarthritis and rheumatoid arthritis. Cochrane Database
Syst Rev 2005. Issue 4. Art. No.:CD004803.
26 Pritchett JW. Patients prefer a bicruciate-retaining or the medial pivot
total knee prosthesis. J Arthroplasty 2011; 26: 224e8.
27 Huang CH, Liau JJ, Cheng CK. Fixed or mobile-bearing total knee
arthroplasty. J Orthop Surg Res 2007; 2: 1.
28 Huang CH, Ma HM, Liau JJ, Ho FY, Cheng CK. Late dislocation of
rotating platform in New Jersey low-contact stress knee prosthesis.
Clin Orthop Relat Res 2002; 189e94.
29 Bhan S, Malhotra R, Kiran EK, Shukla S, Bijjawara M. A comparison
of xed-bearing and mobile-bearing total knee arthroplasty at a
minimum follow-up of 4.5 years. J Bone Joint Surg Am 2005; 87:
2290e6.
30 Watanabe T, Tomita T, Fujii M, Hashimoto J, Sugamoto K,
Yoshikawa H. Comparison between mobile-bearing and xed-
bearing knees in bilateral total knee replacements. Int Orthop
2005; 29: 179e81.
31 Ball ST, Sanchez HB, Mahoney OM, Schmalzried TP. Fixed versus
rotating platform total knee arthroplasty: a prospective, randomized,
single-blind study. J Arthroplasty 2011; 26: 531e6.
32 Stulberg SD, Loan P, Sarin V. Computer-assisted navigation in
total knee replacement: results of an initial experience in
thirty-ve patients. J Bone Joint Surg Am 2002; 84-A(suppl 2):
90e8.
MINI-SYMPOSIUM: THE KNEE
ORTHOPAEDICS AND TRAUMA 27:6 370 2013 Elsevier Ltd. All rights reserved.
33 Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of
alignment outcomes in computer-assisted total knee arthroplasty
surgery. J Arthroplasty 2007; 22: 1097e106.
34 Bauwens K, Matthes G, Wich M, et al. Navigated total knee replace-
ment. A meta-analysis. J Bone Joint Surg Am 2007; 89: 261e9.
35 Barrett WP, Mason JB, Moskal JT, Dalury DF, Oliashirazi A,
Fisher DA. Comparison of radiographic alignment of
imageless computer-assisted surgery vs conventional instru-
mentation in primary total knee arthroplasty. J Arthroplasty
2011; 26: 1273e84. e1.
36 Burnett RS, Barrack RL. Computer-assisted total knee arthroplasty is
currently of no proven clinical benet: a systematic review. Clin
Orthop Relat Res 2013; 471: 264e76.
MINI-SYMPOSIUM: THE KNEE
ORTHOPAEDICS AND TRAUMA 27:6 371 2013 Elsevier Ltd. All rights reserved.