Measurement of knee joint gaps without bone resection: “Physiologic” extension and flexion gaps in total knee arthroplasty are asymmetric and unequal and anterior and posterior cruciate ligament resections produce different gap changes

Nowakowski, A; Majewski, Martin; Müller‐Gerbl, Magdalena; Valderrábano, Víctor

doi:10.1002/jor.21564

Cited by 68 publications

(48 citation statements)

References 30 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The flexion and extension gaps are influenced by various factors, including deformities and osteolysis [4], contractures of the soft tissue mantle [8], operative approach [9], osteophytes [10,11], and eversion of the patella [12,13]. Even preparation of the flexion gap can influence the magnitude of the extension gap [14]. Finally, bony resection can affect capsular and ligamentous tension, and thus also the size of the gaps [15].…”

Section: Introductionmentioning

confidence: 99%

Influence of tibial slope on extension and flexion gaps in total knee arthroplasty: increasing the tibial slope affects both gaps

Nowakowski

Kamphausen

Pagenstert

et al. 2014

International Orthopaedics (SICOT)

Self Cite

View full text Add to dashboard Cite

Purpose Increasing the tibial slope is often performed if the flexion gap is narrower than the extension gap. The main hypothesis of this study is that increasing the tibial slope coincidentally enlarges the extension gap. Methods Twenty formalin-fixed cadaveric knees were obtained for study. After CT in full extension and 90°flexion, the data of each specimen were entered into a standardized coordinate system and virtual bone cuts were performed with incrementally increasing the posterior slope. Gaps were measured at tibiofemoral contact points in 90°-flexion and full extension in the medial and lateral compartment. Results Increasing the tibial slope did significantly widen both the extension and the flexion gaps (p<0.001). In extension, the opening rates, i.e. the gap increase per degree of slope increase, were equal medially and laterally (0.5 mm ±0.1) medial vs 0.6 mm (±0.0) lateral), whereas in flexion the lateral gap did open significantly more than the medial one (0.6 mm ±0.1) medial vs 0.9 mm (±0.1) lateral (p<0.001), resulting in a significantly greater flexion gap laterally.Conclusions Increasing the tibial slope beyond the preoperative planning in order to widen a tight flexion gap intra-operatively is not recommended as doing so will increase the extension gap simultaneously and will make the medial and lateral flexion gaps unequal.

show abstract

Section: Introductionmentioning

confidence: 99%

Influence of tibial slope on extension and flexion gaps in total knee arthroplasty: increasing the tibial slope affects both gaps

Nowakowski

Kamphausen

Pagenstert

et al. 2014

International Orthopaedics (SICOT)

Self Cite

View full text Add to dashboard Cite

show abstract

“…Using applied loads that just engage the soft tissue restraints, the limits of passive motion for a single degree of freedom are quantified as the extremes of the bidirectional motions of the tibia relative to the femur about a neutral position over a range of flexion angles . However prior studies were limited in that they (1) included a limited number of degrees of freedom, (2) measured the limits of passive motion over a limited range of flexion angles, (3) constrained coupled motions, and/or (4) did not address both types of patient‐to‐patient differences in the limits of passive motion …”

mentioning

confidence: 99%

“…4,[8][9][10] Using applied loads that just engage the soft tissue restraints, the limits of passive motion for a single degree of freedom are quantified as the extremes of the bidirectional motions of the tibia relative to the femur about a neutral position over a range of flexion angles. 4 However prior studies were limited in that they (1) included a limited number of degrees of freedom, 4,8,11 (2) measured the limits of passive motion over a limited range of flexion angles, 4,8,11 (3) constrained coupled motions, 9,11 and/or (4) did not address both types of patient-to-patient differences in the limits of passive motion. 4,[8][9][10][11] Accordingly, the primary objective of the present study was to determine how variable the limits of each degree of freedom are between knees by characterizing the range of the limits of passive motion of the normal tibiofemoral joint in each of four degrees of freedom over the full range of flexion without constraining coupled motions.…”

mentioning

confidence: 99%

“…4 However prior studies were limited in that they (1) included a limited number of degrees of freedom, 4,8,11 (2) measured the limits of passive motion over a limited range of flexion angles, 4,8,11 (3) constrained coupled motions, 9,11 and/or (4) did not address both types of patient-to-patient differences in the limits of passive motion. 4,[8][9][10][11] Accordingly, the primary objective of the present study was to determine how variable the limits of each degree of freedom are between knees by characterizing the range of the limits of passive motion of the normal tibiofemoral joint in each of four degrees of freedom over the full range of flexion without constraining coupled motions. The four degrees of freedom include internal-external (I-E) rotation, varus-valgus (V-V) rotation, anterior-posterior (A-P) translation, and compression-distraction (C-D) translation.…”

mentioning

confidence: 99%

See 1 more Smart Citation

The limits of passive motion are variable between and unrelated within normal tibiofemoral joints

Roth

Hull

Howell

2015

Journal Orthopaedic Research

View full text Add to dashboard Cite

Patient-to-patient differences should be accounted for in both clinical evaluations and computational models of knee laxity. Accordingly, the objectives were to determine how variable the laxities are between knees by determining the range of the internal-external (I-E), varus-valgus (V-V), anterior-posterior (A-P), and compression-distraction (C-D) limits of passive motion, and how related the laxities are within a knee by determining whether these limits are correlated with one another. The limits in I-E (AE 3 Nm), V-V (AE 5 Nm), A-P (AE 45 N), and C-D (AE 100 N) were measured in 10 normal human cadaveric knees at 0˚to 120˚flexion in 15i ncrements using a six degree-of-freedom load application system. The ranges from 15˚to 120˚flexion of the I-E limits were greater than 3.6˚, of the A-P limits were greater than 1.8 mm, and of the varus limits were greater than 1.4˚. The ranges from 30˚to 120f exion of the distraction limits were greater than 2.0 mm. Twenty-four of the 28 pair-wise comparisons between the limits had a correlation coefficient less than 0.65. These results demonstrate that a patient-specific approach, including all degrees of freedom of interest, is necessary during clinical evaluations of laxity and when creating and validating computational models of the tibiofemoral joint. Keywords: limits of passive motion; patient-specific modeling; laxity; knee It is important to characterize the patient-to-patient differences in the laxities of the tibiofemoral joint of the normal human knee in various degrees of freedom. The laxities of the normal human knee are often used both as a benchmark by orthopedic surgeons when evaluating laxities before, during, and after surgical interventions (e.g., total knee arthroplasty) 1 and as a gold standard by researchers when validating computational models of the tibiofemoral joint.2,3 Passive kinematics of the tibiofemoral joint are guided by the interaction between the soft tissue restraints and the articular geometry. However, the restraints from both the soft tissues and articular geometry are different between individuals. 4 Because the laxities are a measure of the function of the soft tissue restraints and the articular geometry, abnormal laxities indicate abnormal function. Therefore, it is critical to characterize the patientto-patient differences in the laxities so they may be accounted for during clinical evaluations of laxity and when creating computational models of the knee to study the behavior of the soft tissue restraints.There are two types of patient-to-patient differences that are of interest with regards to the laxities of the tibiofemoral joint. The first is the variability of the laxities between knees. If there is a wide variability as characterized by a wide range of the laxities, then a patient-specific approach would be necessary both during clinical evaluations of laxity and when creating computational models of the knee to study the behavior of the soft tissue restraints. The second is the relationship between the laxity in one ...

show abstract

“…Nowakowski et al demonstrated that the ACL resection increases the extension gap, whereas the PCL resection increases the flexion gap in physiological conditions of young and healthy cadaveric specimens. 21 They removed 10 mm of the periosteum from the medial tibia. The tibial insertion of the dMCL was reported to be 6.6 AE 1.3 mm from the joint line.…”

Section: Discussionmentioning

confidence: 99%

The Influence of Posterior Cruciate Ligament Resection on Tibiofemoral Joint Gap in Varus Osteoarthritic Knees

et al. 2020

View full text Add to dashboard Cite

Posterior cruciate ligament (PCL) resection during posterior-stabilized total knee arthroplasty (PS-TKA) has been reported to preferentially increase the tibiofemoral joint gap in flexion compared with extension. However, previous assessments of the joint gaps have been performed after bone resection and medial soft tissue release. Thus, these procedural steps may have the potential to influence soft tissue balance. In native knees, soft tissue laxity is generally greater in the lateral compartment than in the medial compartment both with the knee in extension and in flexion. Some surgeons may retain this natural soft tissue balance with less aggressive medial release during TKA. We performed this study to evaluate the impact of the PCL resection on the extension and flexion gaps in the absence of bone resection or medial soft tissue release. Tibiofemoral joint gaps for 41 patients (10 males and 31 females) in full extension and at 90 degrees of flexion both before and after the resections of both the anterior cruciate ligament (ACL) and PCL were assessed using a ligament tensioner device. The statistical analyze was performed using the Mann–Whitney U test. The results showed that medial gap in extension and flexion were 6.7 ± 1.0 and 7.3 ± 0.9 mm, and lateral gap in extension and flexion were 7.6 ± 1.1 and 8.4 ± 1.6 mm, respectively. Thus, physiological tibiofemoral gaps just after knee arthrotomy were trapezoidal and asymmetric shape with the significantly wider gaps in lateral and flexion, compared with the medial and extension, respectively (p < 0.05). However, the increases of the gaps with the ACL and PCL resections were less than 1 mm under the existence of medial soft tissues. As the medial collateral ligament is the primary restraint for the valgus instability, it was also considered to prevent the increase of the flexion gap although the PCL—which is the secondary restraint for the valgus instability—was resected. This finding is critically important for orthopedic surgeons applying PS-TKA implants, particularly for preserving soft tissues to achieve natural knee kinematics postoperatively.

show abstract

Measurement of knee joint gaps without bone resection: “Physiologic” extension and flexion gaps in total knee arthroplasty are asymmetric and unequal and anterior and posterior cruciate ligament resections produce different gap changes

Cited by 68 publications

References 30 publications

Influence of tibial slope on extension and flexion gaps in total knee arthroplasty: increasing the tibial slope affects both gaps

Influence of tibial slope on extension and flexion gaps in total knee arthroplasty: increasing the tibial slope affects both gaps

The limits of passive motion are variable between and unrelated within normal tibiofemoral joints

The Influence of Posterior Cruciate Ligament Resection on Tibiofemoral Joint Gap in Varus Osteoarthritic Knees

Contact Info

Product

Resources

About