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J Knee Surg 2020; 33(11): 1121-1127
DOI: 10.1055/s-0039-1692486
Original Article

Femoral Component Malrotation Produces Quadriceps Weakness and Impaired Ambulatory Function following Total Knee Arthroplasty: Results of a Forward-Dynamic Computer Model

John F. Nettrour 
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
,
Swithin S. Razu
2   Department of Bioengineering, University of Missouri, Columbia, Missouri
,
James A. Keeney
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
,
Trent M. Guess
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
3   Department of Physical Therapy, University of Missouri, Columbia, Missouri
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Abstract

Proper placement of the prosthetic components is believed to be an important factor in successful total knee arthroplasty (TKA). Implant positioning errors have been associated with postoperative pain, suboptimal function, and inferior patient-reported outcome measures. The purpose of this study was to investigate the biomechanical effects of femoral component malrotation on quadriceps function and normal ambulation. For the investigation, publicly available data were used to create a validated forward-dynamic, patient-specific computer model. The incorporated data included medical imaging, gait laboratory measurements, knee loading information, electromyographic data, strength testing, and information from the surgical procedure. The ideal femoral component rotation was set to the surgical transepicondylar axis and walking simulations were subsequently performed with increasing degrees of internal and external rotation of the femoral component. The muscle force outputs were then recorded for the quadriceps musculature as a whole, as well as for the individual constituent muscles. The quadriceps work requirements during walking were then calculated for the different rotational simulations. The highest forces generated by the quadriceps were seen during single-limb stance phase as increasing degrees of femoral internal rotation produced proportional increases in quadriceps force requirements. The individual muscles of the quadriceps displayed different sensitivities to the rotational variations introduced into the simulations with the vastus lateralis showing the greatest changes with rotational positioning. Increasing degrees of internal rotation of femoral component were also seen to demand increasing quadriceps work to support normal ambulation. In conclusion, internal malrotation of the femoral component during TKA produces a mechanically disadvantaged state which is characterized by greater required quadriceps forces (especially the vastus lateralis) and greater quadriceps work to support normal ambulation.

Keywords

knee arthroplasty - biomechanics - kinematics - quadriceps function - component rotation


Publication History

Received: 29 November 2018

Accepted: 05 May 2019

Article published online:
03 July 2019

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Anderson JG, Wixson RL, Tsai D, Stulberg SD, Chang RW. Functional outcome and patient satisfaction in total knee patients over the age of 75. J Arthroplasty 1996; 11 (07) 831-840
    CrossrefPubMedGoogle Scholar
  • 2 Borne RB, McCalden RW, MacDonald SJ, Mokete L, Guerin J. Influence of patient factors on TKA outcomes at 5–11 years follow-up. Clin Orthop Relat Res 2007; (464) 21-31
    PubMedGoogle Scholar
  • 3 Ranawat CS, Flynn WF, Saddler S, Hansraj KK, Maynard MJ. Long-term results of the total condylar knee arthroplasty. A 15-year survivorship study. Clin Orthop Relat Res 1993; (286) 94-102
    PubMedGoogle Scholar
  • 4 Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall Award paper. Why are total knee arthroplasties failing today?. Clin Orthop Relat Res 2002; (404) 7-13
    CrossrefPubMedGoogle Scholar
  • 5 Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?. Clin Orthop Relat Res 2010; 468 (01) 57-63
    Google Scholar
  • 6 Chesworth BM, Mahomed NN, Bourne RB, Davis AM. ; OJRR Study Group. Willingness to go through surgery again validated the WOMAC clinically important difference from THR/TKR surgery. J Clin Epidemiol 2008; 61 (09) 907-918
    CrossrefPubMedGoogle Scholar
  • 7 Hawker G, Wright J, Coyte P. et al. Health-related quality of life after knee replacement. J Bone Joint Surg Am 1998; 80 (02) 163-173
    Google Scholar
  • 8 Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthop Relat Res 1985; (192) 13-22
    PubMedGoogle Scholar
  • 9 Choong PF, Dowsey MM, Stoney JD. Does accurate anatomical alignment result in better function and quality of life? Comparing conventional and computer-assisted total knee arthroplasty. J Arthroplasty 2009; 24 (04) 560-569
    Google Scholar
  • 10 Bäthis H, Perlick L, Tingart M, Lüring C, Zurakowski D, Grifka J. Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique. J Bone Joint Surg Br 2004; 86 (05) 682-687
    CrossrefPubMedGoogle Scholar
  • 11 Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS. Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res 1993; (286) 40-47
    PubMedGoogle Scholar
  • 12 Siston RA, Patel JJ, Goodman SB, Delp SL, Giori NJ. The variability of femoral rotational alignment in total knee arthroplasty. J Bone Joint Surg Am 2005; 87 (10) 2276-2280
    PubMedGoogle Scholar
  • 13 Yau WP, Chiu KY, Tang WM. How precise is the determination of rotational alignment of the femoral prosthesis in total knee arthroplasty: an in vivo study. J Arthroplasty 2007; 22 (07) 1042-1048
    Google Scholar
  • 14 Franceschini V, Nodzo SR, Gonzalez Della Valle A. Femoral component rotation in total knee arthroplasty: a comparison between transepicondylar axis and posterior condylar line referencing. J Arthroplasty 2016; 31 (12) 2917-2921
    CrossrefPubMedGoogle Scholar
  • 15 Meric G, Gracitelli GC, Aram LJ, Swank ML, Bugbee WD. Variability in the distal femoral anatomy in patients undergoing total knee arthroplasty: measurements on 13,546 computed tomography scans. J Arthroplasty 2015; 30 (10) 1835-1838
    Google Scholar
  • 16 Kawahara S, Okazaki K, Matsuda S, Nakahara H, Okamoto S, Iwamoto Y. Internal rotation of femoral component affects functional activities after TKA--survey with the 2011 Knee Society Score. J Arthroplasty 2014; 29 (12) 2319-2323
    CrossrefPubMedGoogle Scholar
  • 17 Ghosh KM, Merican AM, Iranpour F, Deehan DJ, Amis AA. The effect of femoral component rotation on the extensor retinaculum of the knee. J Orthop Res 2010; 28 (09) 1136-1141
    CrossrefPubMedGoogle Scholar
  • 18 Boldt JG, Stiehl JB, Hodler J, Zanetti M, Munzinger U. Femoral component rotation and arthrofibrosis following mobile-bearing total knee arthroplasty. Int Orthop 2006; 30 (05) 420-425
    CrossrefPubMedGoogle Scholar
  • 19 Bhattee G, Moonot P, Govindaswamy R, Pope A, Fiddian N, Harvey A. Does malrotation of components correlate with patient dissatisfaction following secondary patellar resurfacing?. Knee 2014; 21 (01) 247-251
    CrossrefPubMedGoogle Scholar
  • 20 Calliess T, Schado S, Richter BI, Becher C, Ezechieli M, Ostermeier S. Quadriceps force during knee extension in different replacement scenarios with a modular partial prosthesis. Clin Biomech (Bristol, Avon) 2014; 29 (02) 218-222
    CrossrefPubMedGoogle Scholar
  • 21 Andriacchi TP. Functional analysis of pre and post-knee surgery: total knee arthroplasty and ACL reconstruction. J Biomech Eng 1993; 115 (4B): 575-581
    CrossrefPubMedGoogle Scholar
  • 22 Li K, Ackland DC, McClelland JA. et al. Trunk muscle action compensates for reduced quadriceps force during walking after total knee arthroplasty. Gait Posture 2013; 38 (01) 79-85
    CrossrefPubMedGoogle Scholar
  • 23 Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler L. Early quadriceps strength loss after total knee arthroplasty. The contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg Am 2005; 87 (05) 1047-1053
    CrossrefPubMedGoogle Scholar
  • 24 Stevens JE, Mizner RL, Snyder-Mackler L. Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis. J Orthop Res 2003; 21 (05) 775-779
    Google Scholar
  • 25 Dorr LD, Ochsner JL, Gronley J, Perry J. Functional comparison of posterior cruciate-retained versus cruciate-sacrificed total knee arthroplasty. Clin Orthop Relat Res 1988; (236) 36-43
    PubMedGoogle Scholar
  • 26 Heyse TJ, Becher C, Kron N. et al. Quadriceps force in relation of intrinsic anteroposterior stability of TKA design. Arch Orthop Trauma Surg 2010; 130 (01) 1-9
    CrossrefPubMedGoogle Scholar
  • 27 Rand JA. The patellofemoral joint in total knee arthroplasty. J Bone Joint Surg Am 1994; 76 (04) 612-620
    CrossrefPubMedGoogle Scholar
  • 28 Elias JJ, Bratton DR, Weinstein DM, Cosgarea AJ. Comparing two estimations of the quadriceps force distribution for use during patellofemoral simulation. J Biomech 2006; 39 (05) 865-872
    CrossrefPubMedGoogle Scholar
  • 29 Dennis DA, Komistek RD, Colwell Jr CE. et al. In vivo anteroposterior femorotibial translation of total knee arthroplasty: a multicenter analysis. Clin Orthop Relat Res 1998; (356) 47-57
    CrossrefPubMedGoogle Scholar
  • 30 Fregly BJ, Besier TF, Lloyd DG. et al. Grand challenge competition to predict in vivo knee loads. J Orthop Res 2012; 30 (04) 503-513
    CrossrefPubMedGoogle Scholar
  • 31 Razu SS, Guess TM. Electromyography-driven forward dynamics simulation to estimate in vivo joint contact forces during normal, smooth, and bouncy gaits. J Biomech Eng 2018; 140 (07) 0710121-0710128
    PubMedGoogle Scholar
  • 32 Thompson JA, Hast MW, Granger JF, Piazza SJ, Siston RA. Biomechanical effects of total knee arthroplasty component malrotation: a computational simulation. J Orthop Res 2011; 29 (07) 969-975
    CrossrefPubMedGoogle Scholar
  • 33 Bell SW, Young P, Drury C. et al. Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee 2014; 21 (01) 272-277
    Google Scholar
  • 34 Czurda T, Fennema P, Baumgartner M, Ritschl P. The association between component malalignment and post-operative pain following navigation-assisted total knee arthroplasty: results of a cohort/nested case-control study. Knee Surg Sports Traumatol Arthrosc 2010; 18 (07) 863-869
    CrossrefPubMedGoogle Scholar
  • 35 Murakami AM, Hash TW, Hepinstall MS, Lyman S, Nestor BJ, Potter HG. MRI evaluation of rotational alignment and synovitis in patients with pain after total knee replacement. J Bone Joint Surg Br 2012; 94 (09) 1209-1215
    CrossrefPubMedGoogle Scholar
  • 36 Lakstein D, Zarrabian M, Kosashvili Y, Safir O, Gross AE, Backstein D. Revision total knee arthroplasty for component malrotation is highly beneficial: a case control study. J Arthroplasty 2010; 25 (07) 1047-1052
    Google Scholar
  • 37 Pietsch M, Hofmann S. Early revision for isolated internal malrotation of the femoral component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2012; 20 (06) 1057-1063
    CrossrefPubMedGoogle Scholar
  • 38 Incavo SJ, Wild JJ, Coughlin KM, Beynnon BD. Early revision for component malrotation in total knee arthroplasty. Clin Orthop Relat Res 2007; 458 (458) 131-136
    CrossrefPubMedGoogle Scholar
  • 39 Sternheim A, Lochab J, Drexler M. et al. The benefit of revision knee arthroplasty for component malrotation after primary total knee replacement. Int Orthop 2012; 36 (12) 2473-2478
    CrossrefPubMedGoogle Scholar