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

*Corresponding author for this work

    Research output: Contribution to journalArticleAcademicpeer-review

    2 Citations (Scopus)
    62 Downloads (Pure)

    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

    Fingerprint

    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.
    @article{e656ab9e97354c7bba487e8f8a4ae176,
    title = "Flexing and downsizing the femoral component is not detrimental to patellofemoral biomechanics in posterior-referencing cruciate-retaining total knee arthroplasty",
    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.",
    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",
    author = "Marra, {Marco A.} and Marta Strzelczak and Heesterbeek, {Petra J.C.} and {van de Groes}, {Sebastiaan A.W.} and Dennis Janssen and Koopman, {Bart F.J.M.} and Nico Verdonschot and Wymenga, {Ate B.}",
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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

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