Flexing and downsizing the femoral component is not detrimental to patellofemoral biomechanics in posterior-referencing cruciate-retaining total knee arthroplasty

Marco A. Marra (Corresponding Author), Marta Strzelczak, Petra J.C. Heesterbeek, Sebastiaan A.W. van de Groes, Dennis Janssen, Bart F.J.M. Koopman, Nico Verdonschot, Ate B. Wymenga

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Abstract

Purpose: When downsizing the femoral component to prevent mediolateral overhang, notching of the anterior femoral cortex may occur, which could be solved by flexing the femoral component. In this study, we investigated the effect of flexion of the femoral component on patellar tendon moment arm, patellofemoral forces and kinematics in posterior-referencing CR-TKA. Our hypothesis was that flexion of the femoral component increases the patellar tendon moment arm, reduces the patellofemoral forces and provides stable kinematics. Methods: A validated musculoskeletal model of CR-TKA was used. The flexion of the femoral component was increased in four steps (0°, 3°, 6°, 9°) using posterior referencing, and different alignments were analysed in combination with three implant sizes (3, 4, 5). A chair-rising trial was analysed using the model, while simultaneously estimating quadriceps muscle force, patellofemoral contact force, tibiofemoral and patellofemoral kinematics. Results: Compared to the reference case (size 4 and 0° flexion), for every 3° of increase in flexion of the femoral component the patellar tendon moment arm increased by 1% at knee extension. The peak quadriceps muscle force and patellofemoral contact force decreased by 2%, the patella shifted 0.8 mm more anteriorly and the remaining kinematics remained stable, with knee flexion. With the smaller size, the patellar tendon moment arm decreased by 6%, the quadriceps muscle force and patellofemoral contact force increased by 8 and 12%, and the patellar shifted 5 mm more posteriorly. Opposite trends were found with the bigger size. Conclusion: Flexing the femoral component with posterior referencing reduced the patellofemoral contact forces during a simulated chair-rising trial with a patient-specific musculoskeletal model of CR-TKA. There seems to be little risk when flexing and downsizing the femoral component, compared to when using a bigger size and neutral alignment. These findings provide relevant information to surgeons who wish to prevent anterior notching when downsizing the femoral component.

Original languageEnglish
Pages (from-to)3377-3385
Number of pages9
JournalKnee surgery, sports traumatology, arthroscopy
Volume26
Issue number11
Early online date20 Mar 2018
DOIs
Publication statusPublished - 1 Nov 2018

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Knee Replacement Arthroplasties
Thigh
Biomechanical Phenomena
Patellar Ligament
Quadriceps Muscle
Knee
Patella

Keywords

  • UT-Hybrid-D
  • Biomechanics
  • Chair
  • Component
  • CR
  • Femoral
  • Flexion
  • Force
  • Model
  • Musculoskeletal
  • Patellofemoral
  • Posterior-referencing
  • Quadriceps
  • Rising
  • Sagittal
  • TKA
  • Total knee arthroplasty
  • Total knee replacement
  • Alignment

Cite this

Marra, Marco A. ; Strzelczak, Marta ; Heesterbeek, Petra J.C. ; van de Groes, Sebastiaan A.W. ; Janssen, Dennis ; Koopman, Bart F.J.M. ; Verdonschot, Nico ; Wymenga, Ate B. / Flexing and downsizing the femoral component is not detrimental to patellofemoral biomechanics in posterior-referencing cruciate-retaining total knee arthroplasty. In: Knee surgery, sports traumatology, arthroscopy. 2018 ; Vol. 26, No. 11. pp. 3377-3385.
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abstract = "Purpose: When downsizing the femoral component to prevent mediolateral overhang, notching of the anterior femoral cortex may occur, which could be solved by flexing the femoral component. In this study, we investigated the effect of flexion of the femoral component on patellar tendon moment arm, patellofemoral forces and kinematics in posterior-referencing CR-TKA. Our hypothesis was that flexion of the femoral component increases the patellar tendon moment arm, reduces the patellofemoral forces and provides stable kinematics. Methods: A validated musculoskeletal model of CR-TKA was used. The flexion of the femoral component was increased in four steps (0°, 3°, 6°, 9°) using posterior referencing, and different alignments were analysed in combination with three implant sizes (3, 4, 5). A chair-rising trial was analysed using the model, while simultaneously estimating quadriceps muscle force, patellofemoral contact force, tibiofemoral and patellofemoral kinematics. Results: Compared to the reference case (size 4 and 0° flexion), for every 3° of increase in flexion of the femoral component the patellar tendon moment arm increased by 1{\%} at knee extension. The peak quadriceps muscle force and patellofemoral contact force decreased by 2{\%}, the patella shifted 0.8 mm more anteriorly and the remaining kinematics remained stable, with knee flexion. With the smaller size, the patellar tendon moment arm decreased by 6{\%}, the quadriceps muscle force and patellofemoral contact force increased by 8 and 12{\%}, and the patellar shifted 5 mm more posteriorly. Opposite trends were found with the bigger size. Conclusion: Flexing the femoral component with posterior referencing reduced the patellofemoral contact forces during a simulated chair-rising trial with a patient-specific musculoskeletal model of CR-TKA. There seems to be little risk when flexing and downsizing the femoral component, compared to when using a bigger size and neutral alignment. These findings provide relevant information to surgeons who wish to prevent anterior notching when downsizing the femoral component.",
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Flexing and downsizing the femoral component is not detrimental to patellofemoral biomechanics in posterior-referencing cruciate-retaining total knee arthroplasty. / Marra, Marco A. (Corresponding Author); Strzelczak, Marta; Heesterbeek, Petra J.C.; van de Groes, Sebastiaan A.W.; Janssen, Dennis; Koopman, Bart F.J.M.; Verdonschot, Nico; Wymenga, Ate B.

In: Knee surgery, sports traumatology, arthroscopy, Vol. 26, No. 11, 01.11.2018, p. 3377-3385.

Research output: Contribution to journalArticleAcademicpeer-review

TY - JOUR

T1 - Flexing and downsizing the femoral component is not detrimental to patellofemoral biomechanics in posterior-referencing cruciate-retaining total knee arthroplasty

AU - Marra, Marco A.

AU - Strzelczak, Marta

AU - Heesterbeek, Petra J.C.

AU - van de Groes, Sebastiaan A.W.

AU - Janssen, Dennis

AU - Koopman, Bart F.J.M.

AU - Verdonschot, Nico

AU - Wymenga, Ate B.

N1 - Springer deal

PY - 2018/11/1

Y1 - 2018/11/1

N2 - Purpose: When downsizing the femoral component to prevent mediolateral overhang, notching of the anterior femoral cortex may occur, which could be solved by flexing the femoral component. In this study, we investigated the effect of flexion of the femoral component on patellar tendon moment arm, patellofemoral forces and kinematics in posterior-referencing CR-TKA. Our hypothesis was that flexion of the femoral component increases the patellar tendon moment arm, reduces the patellofemoral forces and provides stable kinematics. Methods: A validated musculoskeletal model of CR-TKA was used. The flexion of the femoral component was increased in four steps (0°, 3°, 6°, 9°) using posterior referencing, and different alignments were analysed in combination with three implant sizes (3, 4, 5). A chair-rising trial was analysed using the model, while simultaneously estimating quadriceps muscle force, patellofemoral contact force, tibiofemoral and patellofemoral kinematics. Results: Compared to the reference case (size 4 and 0° flexion), for every 3° of increase in flexion of the femoral component the patellar tendon moment arm increased by 1% at knee extension. The peak quadriceps muscle force and patellofemoral contact force decreased by 2%, the patella shifted 0.8 mm more anteriorly and the remaining kinematics remained stable, with knee flexion. With the smaller size, the patellar tendon moment arm decreased by 6%, the quadriceps muscle force and patellofemoral contact force increased by 8 and 12%, and the patellar shifted 5 mm more posteriorly. Opposite trends were found with the bigger size. Conclusion: Flexing the femoral component with posterior referencing reduced the patellofemoral contact forces during a simulated chair-rising trial with a patient-specific musculoskeletal model of CR-TKA. There seems to be little risk when flexing and downsizing the femoral component, compared to when using a bigger size and neutral alignment. These findings provide relevant information to surgeons who wish to prevent anterior notching when downsizing the femoral component.

AB - Purpose: When downsizing the femoral component to prevent mediolateral overhang, notching of the anterior femoral cortex may occur, which could be solved by flexing the femoral component. In this study, we investigated the effect of flexion of the femoral component on patellar tendon moment arm, patellofemoral forces and kinematics in posterior-referencing CR-TKA. Our hypothesis was that flexion of the femoral component increases the patellar tendon moment arm, reduces the patellofemoral forces and provides stable kinematics. Methods: A validated musculoskeletal model of CR-TKA was used. The flexion of the femoral component was increased in four steps (0°, 3°, 6°, 9°) using posterior referencing, and different alignments were analysed in combination with three implant sizes (3, 4, 5). A chair-rising trial was analysed using the model, while simultaneously estimating quadriceps muscle force, patellofemoral contact force, tibiofemoral and patellofemoral kinematics. Results: Compared to the reference case (size 4 and 0° flexion), for every 3° of increase in flexion of the femoral component the patellar tendon moment arm increased by 1% at knee extension. The peak quadriceps muscle force and patellofemoral contact force decreased by 2%, the patella shifted 0.8 mm more anteriorly and the remaining kinematics remained stable, with knee flexion. With the smaller size, the patellar tendon moment arm decreased by 6%, the quadriceps muscle force and patellofemoral contact force increased by 8 and 12%, and the patellar shifted 5 mm more posteriorly. Opposite trends were found with the bigger size. Conclusion: Flexing the femoral component with posterior referencing reduced the patellofemoral contact forces during a simulated chair-rising trial with a patient-specific musculoskeletal model of CR-TKA. There seems to be little risk when flexing and downsizing the femoral component, compared to when using a bigger size and neutral alignment. These findings provide relevant information to surgeons who wish to prevent anterior notching when downsizing the femoral component.

KW - UT-Hybrid-D

KW - Biomechanics

KW - Chair

KW - Component

KW - CR

KW - Femoral

KW - Flexion

KW - Force

KW - Model

KW - Musculoskeletal

KW - Patellofemoral

KW - Posterior-referencing

KW - Quadriceps

KW - Rising

KW - Sagittal

KW - TKA

KW - Total knee arthroplasty

KW - Total knee replacement

KW - Alignment

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U2 - 10.1007/s00167-018-4900-z

DO - 10.1007/s00167-018-4900-z

M3 - Article

VL - 26

SP - 3377

EP - 3385

JO - Knee surgery, sports traumatology, arthroscopy

JF - Knee surgery, sports traumatology, arthroscopy

SN - 0942-2056

IS - 11

ER -