Assessing the risk of tibial baseplate loosening in patients after unrestricted kinematically aligned (unKA) total knee arthroplasty (TKA) using a medially conforming insert is important because ...baseplates generally are aligned in varus which has been linked to an increased incidence of aseptic loosening following mechanically aligned TKA. Two limits that indicate long-term stability in patients are a change in maximum total point motion between 1 and 2 years (ΔMTPM) < 0.2 mm and anterior tilt at 2 years < 0.8°. The purposes were to determine: (1) the number of patients with ΔMTPM > 0.2 mm, (2) the number of patients with anterior tilt > 0.8° and (3) whether increased varus baseplate and limb alignment were associated with increased migration.
Thirty-five patients underwent cemented, caliper-verified, unKA TKA using a medially conforming tibial insert with posterior cruciate ligament (PCL) retention. Biplanar radiographs acquired on the day of surgery and at 1.5, 3, 6, 12 and 24 months were processed with model-based radiostereometric analysis (RSA) software to determine migration and the number of patients with migration above the two stability limits. Medial proximal tibial angle (MPTA), hip-knee-ankle angle (HKAA) and posterior slope angle (PSA) were analyzed for an association with migration in six degrees of freedom and in MTPM.
Thirty-two of 35 patients were available for analysis at 2 years. One patient exhibited ΔMTPM > 0.2 mm. The same patient exhibited anterior tilt > 0.8°. Varus rotation (p = 0.048, r ≤ 0.34) and medial translation (p = 0.0273, r ≤ 0.29) increased with increased varus baseplate alignment.
The results indicate low risk of long-term baseplate loosening in patients. Although varus rotation and medial translation increased with increased varus baseplate alignment, the magnitudes of the migrations were minimal and did not increase ΔMTPM and anterior tilt.
Level II, therapeutic prospective cohort study.
Though stuttering is manifest in its motor characteristics, the cause of stuttering may not relate purely to impairments in the motor system as stuttering frequency is increased by linguistic ...factors, such as syntactic complexity and length of utterance, and decreased by changes in perception, such as masking or altering auditory feedback. Using functional and diffusion imaging, we examined brain structure and function in the motor and language areas in a group of young people who stutter. During speech production, irrespective of fluency or auditory feedback, the people who stuttered showed overactivity relative to controls in the anterior insula, cerebellum and midbrain bilaterally and underactivity in the ventral premotor, Rolandic opercular and sensorimotor cortex bilaterally and Heschl's gyrus on the left. These results are consistent with a recent meta-analysis of functional imaging studies in developmental stuttering. Two additional findings emerged from our study. First, we found overactivity in the midbrain, which was at the level of the substantia nigra and extended to the pedunculopontine nucleus, red nucleus and subthalamic nucleus. This overactivity is consistent with suggestions in previous studies of abnormal function of the basal ganglia or excessive dopamine in people who stutter. Second, we found underactivity of the cortical motor and premotor areas associated with articulation and speech production. Analysis of the diffusion data revealed that the integrity of the white matter underlying the underactive areas in ventral premotor cortex was reduced in people who stutter. The white matter tracts in this area via connections with posterior superior temporal and inferior parietal cortex provide a substrate for the integration of articulatory planning and sensory feedback, and via connections with primary motor cortex, a substrate for execution of articulatory movements. Our data support the conclusion that stuttering is a disorder related primarily to disruption in the cortical and subcortical neural systems supporting the selection, initiation and execution of motor sequences necessary for fluent speech production.
Abstract Knowing the accuracy of laser scanners is imperative to select the best scanner to generate bone models. However, errors stated by manufacturers may not apply to bones. The three objectives ...of this study were to determine: 1) whether the overall error stated by the manufacturers of five laser scanners was different from the root mean squared error (RMSE) computed by scanning a gage block; 2) the repeatability of 3D models generated by the laser scanners when scanning a complex freeform surface such as a distal femur and whether this differed from the repeatability when scanning a gage block; 3) whether the errors for one lower-cost laser scanner are comparable to those of four higher-cost laser scanners. The RMSEs in scanning the gage block were 2 to 52 µm lower than the overall errors stated by the manufacturers. The repeatability in scanning the bovine femur 10 times was significantly worse than that in scanning the gage block 10 times. The precision of the lower-cost laser scanner was comparable to that of the higher-cost laser scanners, but the bias was an order of magnitude greater. The contributions of this study are that 1) the overall errors stated by the manufacturers are an upper bound when simple geometric objects like a gage block are scanned, 2) the repeatability is worse on average three times when scanning a complex freeform surface compared to scanning the gage block, and 3) the main difference between the lower-cost and the higher-cost laser scanners is the bias.
Background
Coronal alignment may impact clinical outcome and survivorship in TKA. Patient-specific instrumentation has been developed to restore mechanical or kinematic axis and potentially reduce ...component malpositioning. Although it is clear these instruments add cost, it is unclear whether they improve alignment.
Questions/purposes
We determined whether the mean coronal alignment after TKA performed with conventional versus patient-specific instrumentation better restored the mechanical and kinematic axes and whether there were more outliers with one of the two methods.
Methods
We retrospectively evaluated 150 primary TKAs performed for osteoarthritis: Group 1 (n = 50) conventional instrumentation; Group 2 (n = 50) patient-specific instrumentation restoring the mechanical axis; Group 3 (n = 50) patient-specific instrumentation restoring the kinematic axis, and measured femorotibial angle, hip-knee-ankle angle, and the zone of the mechanical axis from scout CT images taken 0 to 6 weeks postoperatively.
Results
The mean femorotibial angle differed between the groups: Group 1 had the greatest varus mean alignment and most varus outliers. The mean hip-knee angle was similar between Groups 1 and 2, with Group 3 having greater valgus mean alignment and the most valgus outliers. For the zone of the mechanical axis, Groups 1 and 2 had similar percentages of outliers (40% versus 32%), whereas Group 3 had a greater number of outliers (64%) that were valgus.
Conclusions
TKAs with patient-specific instrumentation restoring the mechanical axis had a similar number of outliers as conventional instrumentation with both groups having more varus outliers than TKAs with patient-specific instrumentation restoring kinematic axis, which had more valgus outliers. Therefore, additional studies are needed to determine whether patient-specific instrumentation improves clinical function or patient satisfaction and whether their routine use can be justified in primary TKA.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Purpose
Surgeons performing total knee arthroplasty (TKA) on the osteoarthritic valgus deformity often use a posterior stabilized (PS) and semi-constrained implants to substitute for the release of a ...contracted posterior cruciate ligament (PCL) instead of a cruciate retaining (CR) implant. Calipered kinematic alignment (KA) strives to retain the PCL and use a CR implant. The aim of this study of the windswept deformity was to determine whether the level of implant constraint, outcome scores, and alignment after bilateral calipered KA TKA are different between a pair of knees with a varus and valgus deformity in the same patient.
Methods
A review of a prospectively collected database identified all patients with a windswept deformity treated with bilateral TKA (
n
= 19) out of 2430 consecutive primary TKAs performed between 2014 and 2019. Operative reports determined the level of implant constraint. Patient response to the Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) assessed outcomes at a mean follow-up of 2.3 years. Postoperative alignment was measured on an A-P computer tomographic scanogram of the limb.
Results
CR implants were used in 15 of 19 (79%) valgus deformities and 17 of 19 (89%) of varus deformities (n.s.). No knees required a semi-constrained implant. There was no difference in the median postoperative FJS and OKS (n.s.), and a 1° or less difference in the mean postoperative distal lateral femoral angle (
p
= 0.005) and proximal medial tibial angle (n.s.) between the paired varus and valgus knee deformity.
Conclusion
Based on this small series, surgeons that use calipered KA TKA can expect to use CR implants in most patients with windswept deformity and achieve comparable outcome scores and alignment between the paired varus and valgus deformity.
Level of evidence
IV
Because model-based radiostereometric analysis (MBRSA) identifies tibial baseplate designs which increase risk of baseplate loosening, and because registration errors for computer-aided design (CAD) ...models are large relative to a 6-month stability limit, 3D models more representative of the geometry of implanted baseplates are needed to minimize error. This study tested whether (1) each of three reverse-engineered (RE) models of the same nominal size reduced registration error relative to the equivalent size CAD model, and (2) RE models of multiple sizes reduced registration error relative to CAD models of corresponding sizes. Registration error, quantified as mean artifactual maximum total point motion (aMTPM), was computed between double biplanar radiographs (i.e., two pairs of independent biplanar radiographs from the same day) for thirty-five patients. Double biplanar radiographs were analyzed four times for the most common baseplate size (i.e., size 5) using three RE models and the corresponding CAD model (1st hypothesis) and twice for all patients using one RE model and the equivalent size CAD model (2nd hypothesis). For all three size 5 RE models, mean aMTPM was less than that of the CAD model, though only one RE model reached statistical significance. For multiple size models, mean aMTPM was reduced by 24% when using RE models instead of CAD models, which could mean the difference between categorizing a baseplate as at-risk versus not at-risk relative to a 6-month stability limit. Since error reduction is related to geometry of specific baseplate designs, other baseplate designs should be evaluated using methods presented herein.
Abstract Background Kinematically aligned total knee arthroplasty uses a femoral component designed for mechanical alignment (MA) and sets the component in more internal, valgus, and flexion rotation ...than MA. It is unknown how much kinematic alignment (KA) and flexion of the femoral component reduce the proximal and lateral reach of the trochlea; two reductions that could increase the risk of abnormal patella tracking. Methods We simulated MA and KA of the femoral component in 0° of flexion on 20 3-dimensional bone models of normal femurs. The mechanically and kinematically aligned components were then aligned in 5°, 10°, and 15° of flexion and downsized until the flange contacted the anterior femur. The reductions in the proximal and lateral reach from the proximal point of the trochlea of the MA component set in 0° of flexion were computed. Results KA at 0° of flexion did not reduce the proximal reach and reduced the lateral reach an average of 3 mm. Flexion of the MA and KA femoral component 5°, 10°, and 15° reduced the proximal reach an average of 4 mm, 8 mm, and 12 mm, respectively (0.8 mm/degree of flexion), and reduced the lateral reach an average of 1 mm and 4 mm regardless of the degree of flexion, respectively. Conclusion Arthroplasty surgeons and biomechanical engineers striving to optimize patella tracking might consider developing surgical techniques to minimize flexion of the femoral component when performing KA and MA total knee arthroplasty to promote early patella engagement and consider designing a femoral component with a trochlea shaped specifically for KA.
There are no reports as to whether the condition of the anterior cruciate ligament (ACL) adversely affects the 2 to 3 year function and reoperation risk of a kinematically aligned (KA) total knee ...arthroplasty (TKA) performed with posterior cruciate ligament (PCL) retention and an intermediate medial conforming (MC) insert.
A single surgeon's prospective database query identified 418 consecutive primary TKAs performed between January 2019 and December 2019. The surgeon recorded the ACL condition in the operative note. Patients filled out the Forgotten Joint Score (FJS), Oxford knee score (OKS), and Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement at the final follow-up. There were 299 patients with an intact ACL, 99 with a torn ACL, and 20 with a reconstructed ACL. The mean follow-up was 31 months (range, 20 to 45).
The median FJS, OKS, and Knee Injury and Osteoarthritis Outcome Score (KOOS) of the reconstructed/torn/intact KA TKAs were 90/79/67, 47/44/43, and 92/88/80 points, respectively. The median OKS and KOOS of the reconstructed ACL cohort were 4 and 11 points higher than in the intact ACL cohort (P = .003, .04). One patient who had a reconstructed ACL underwent manipulation under anesthesia (MUA) for stiffness. The 5 reoperations in the intact ACL cohort were for instability (n = 2), revision after failed MUA for stiffness (n = 2), and infection (n = 1).
These results suggest that patients who have a torn and reconstructed ACL can expect high function and a low risk of reoperation comparable to patients who have an intact ACL when treated with unrestricted, caliper-verified KA, PCL retention, and an intermediate MC insert.
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