Yonsei Med J.  2020 Mar;61(3):201-209. 10.3349/ymj.2020.61.3.201.

Kinematically Aligned Total Knee Arthroplasty with Patient-Specific Instrument

• Kim KK
• Howell SM
• Won YY

• KMID: 2470916
• DOI: http://doi.org/10.3349/ymj.2020.61.3.201

Abstract

Kinematically aligned total knee arthroplasty (TKA) is a new alignment technique. Kinematic alignment corrects arthritic deformity to the patient's constitutional alignment in order to position the femoral and tibial components, as well as to restore the knee's natural tibial-femoral articular surface, alignment, and natural laxity. Kinematic knee motion moves around a single flexion-extension axis of the distal femur, passing through the center of cylindrically shaped posterior femoral condyles. Since it can be difficult to locate cylindrical axis with conventional instrument, patient-specific instrument (PSI) is used to align the kinematic axes. PSI was recently introduced as a new technology with the goal of improving the accuracy of operative technique, avoiding practical issues related to the complexity of navigation and robotic system, such as the costs and higher number of personnel required. There are several limitations to implement the kinematically aligned TKA with the implant for mechanical alignment. Therefore, it is important to design an implant with the optimal shape for restoring natural knee kinematics that might improve patient-reported satisfaction and function.

Keyword

Kinematic alignment; mechanical alignment; total knee arthroplasty; patient-specific instrument

MeSH Terms

Arthroplasty, Replacement, Knee*
Biomechanical Phenomena
Congenital Abnormalities
Femur
Knee

Figure

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  Fig. 1 The knee has three kinematic axes. Yellow line shows the longitudinal axis in the tibia that the tibia on the femur rotates about. In the femur, the green line shows transverse axes about which the tibia flexes and extends. Magenta line indicates the transverse axis of the femur that the patella flexes and extends about.

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  Fig. 2 From the upper margin, distal one-third to metaphyseal flare of the femur was registered with points by pen, which made a truncated cone. The distal femoral flexion axis was obtained as a line passing through the center of the truncated cone to the best fit.

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  Fig. 3 Preoperative determination of primary femoral axis. (A) Surfaces of each distal femoral condyle were marked from the distal portion in order to recess to posterior end of posterior condyles. (B) The best-fit sphere from each condyle was made from registered points, and putative positioning of sphere's center was equidistant from pre-arthritic articular surface. (C) Cylindrical axis was made by connecting the centers of two spheres.

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  Fig. 4 Preoperative determination of tibial alignment. (A) The registration process involved a surface centroid excluding regional bone defect and tibial spines. (B) Tibial resection was planned by the plane of best fit to both plateaus (overall arthritic plateau).

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  Fig. 5 Preoperative determination of guide pin location. (A) Patient-specific instrument (PSI) was manufactured by considering the distance between pin hole and saw slot of the cutting block. (B) PSI was applied to the three-dimensional (3D) model of the patient's tibia which was manufactured by 3D printer.

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  Fig. 6 Intra-operative measurement of anterior offset of the tibia from the femur. (A) Intra-operative images of a left knee with varus deformity in 90° of flexion demonstrate the measurement of anterior offset of the tibia from the worn distal medial articular surface of the femur. (B) In order to restore the slope of the native proximal tibial joint line, the anterior-posterior slope and thickness of the tibial component are adjusted until the anterior tibia offset from the distal medial femoral condyle matches that of the knee at the time of exposure.

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  Fig. 7 This composite shows the tibiofemoral relationship of medial and lateral compartments of the native knee in full extension and full extension, in which medial femoral condyle hardly moves (orange square) and lateral femoral condyle rolls posterior in full flexion (orange rectangle). The design of cruciate retaining (CR) insert, consisting of a medial ball-and-socket and a lateral flat surface without a posterior rim, is a promising strategy for promoting A-P stability and reducing the risk of late tibial component failure from posterior rim wear of the insert.

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