Clin Orthop Surg.  2014 Jun;6(2):117-126. 10.4055/cios.2014.6.2.117.

Biomechanics of Hyperflexion and Kneeling before and after Total Knee Arthroplasty

• Lee TQ

• KMID: 1784656
• DOI: http://doi.org/10.4055/cios.2014.6.2.117

Abstract

The capacity to perform certain activities is frequently compromised after total knee arthroplasty (TKA) due to a functional decline resulting from decreased range of motion and a diminished ability to kneel. In this manuscript, the current biomechanical understanding of hyperflexion and kneeling before and after TKA will be discussed. Patellofemoral and tibiofemoral joint contact area, contact pressure, and kinematics were evaluated in cadaveric studies using a Tekscan pressure measuring system and Microscribe. Testing was performed on intact knees and following cruciate retaining and posterior stabilized TKA at knee flexion angles of 90degrees, 105degrees, 120degrees, and 135degrees. Three loading conditions were used to simulate squatting, double stance kneeling, and single stance kneeling. Following TKA with double stance kneeling, patellofemoral contact areas did not increase significantly at high knee flexion angle (135degrees). Kneeling resulted in tibial posterior translation and external rotation at all flexion angles. Moving from double to single stance kneeling tended to increase pressures in the cruciate retaining group, but decreased pressures in the posterior stabilized group. The cruciate retaining group had significantly larger contact areas than the posterior stabilized group, although no significant differences in pressures were observed comparing the two TKA designs (p < 0.05). If greater than 120degrees of postoperative knee range of motion can be achieved following TKA, then kneeling may be performed with less risk in the patellofemoral joint than was previously believed to be the case. However, kneeling may increase the likelihood of damage to cartilage and menisci in intact knees and after TKA increases in tibiofemoral contact area and pressures may lead to polyethyelene wear if performed on a chronic, repetitive basis.

Keyword

Total knee arthroplasty; Kneeling; Hyperflexion; Biomechanics

MeSH Terms

*Arthroplasty, Replacement, Knee
Biomechanical Phenomena
Cadaver
Humans
Knee Joint/*physiopathology/surgery
Osteoarthritis, Knee/*physiopathology/surgery
Patellofemoral Joint/physiopathology/surgery
Posture/physiology
Range of Motion, Articular

Figure

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  Fig. 1 Custom testing sytem used for the quantification of effect of kneeling on patellofemoral joint contact for the intact, normal knee (A) and following total knee arthroplasty (B).

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  Fig. 2 Measurement of patellofemoral angle and patellotibial angle (A) and patellar tilt (B).

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  Fig. 3 Representative Fuji film patellofemoral joint contact patterns for squatting and double stance kneeling.

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  Fig. 4 Histogram showing resultant force for the intact knee with kneeling. *p < 0.05 vs. squatting. †p < 0.05 vs. single stance kneeling.

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  Fig. 5 Histogram showing resultant force following total knee arthroplasty with kneeling. *p < 0.05 vs. squatting. †p < 0.05 vs. single stance kneeling.

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  Fig. 6 Testing setup for quantifying the tibiofemoral contact and kinematics with kneeling.

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  Fig. 7 Representative Tekscan images of tibiofemoral contact patterns of an intact knee and following total knee arthroplasty (TKA).

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  Fig. 8 Tibial translation with kneeling averaged across all knee flexion angles for intact knees, and following cruciate retaining and posterior stabilized total knee arthroplasty (TKA).

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  Fig. 9 Tibial external rotation with kneeling averaged across all knee flexion angles for intact knees, and following cruciate retaining and posterior stabilized total knee arthroplasty (TKA).

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