Medial Overhang of the Tibial Component Is Associated With Higher Risk of Inferior Knee Injury and Osteoarthritis Outcome Score Pain After Knee Replacement

doi:10.1016/j.arth.2017.12.027

The Journal of Arthroplasty

Volume 33, Issue 5, May 2018, Pages 1394-1398

https://doi.org/10.1016/j.arth.2017.12.027 Get rights and content

Abstract

Background

The aim of this prospective multicenter study is to investigate the association among (1) tibial site-specific overhang of medial, anterior, and lateral overhang in relation to Knee Injury and Osteoarthritis Outcome Score pain 1 year after surgery (1 Y KOOS pain) and (2) the malalignment of TKA components including overall malalignment in relation to 1 Y KOOS pain.

Methods

From 10 centers, across 4 continents, 323 patients were enrolled from October 2011 to February 2014. Radiographs were analyzed for tibial overhang on medial, anterior, and lateral site and for overall, tibial, femur, and combined malalignment. A 1 Y KOOS pain score <70 represented an unsatisfactory pain level.

Results

A significant association was observed between medial overhang and 1 Y KOOS pain with a cut-off of <70 (P = .04), with an odds ratio of 0.46. No significant associations were observed among the independent variables of lateral and anterior overhang or for overall, tibial, femoral, and combined component malalignment, and the dependent variable of 1 Y KOOS pain <70.

Conclusion

This prospective multicenter study showed a significant association between medial overhang of the tibial component and a 1 Y KOOS pain <70. The related odds ratio was 0.46, which demonstrates that medial overhang may lead to a 54% reduced chance for entering an acceptable pain category 1 year after surgery when receiving a TKA.

Section snippets

Method

This prospective multicenter was conducted at 10 centers in 4 continents. A total of 323 patients undergoing unilateral TKA were enrolled. One hundred twelve patients were enrolled in Europe from 3 centers (2 centers in Denmark and 1 in Sweden); 98 patients in the United States from 4 centers (Massachusetts, California, Wisconsin, and Tennessee), 81 patients from Asia all from 2 South Korean centers, and 32 patients from 1 center in Australia (Sydney). All patients consented to be followed up

Results

Of the 323 patients enrolled in the study, 68.4% (211) were women, mean BMI was 30.7 kg/m² (SD 8.2), and the mean age was 66.0 years (SD 8.2).

All the included patients had 1 Y KOOS pain, 292 had postoperative AP films and 286 had lateral films. All 292 AP films and 286 lateral films qualified for analysis of medial/lateral and anterior overhang, respectively. Of the 292 postoperative AP films, 286 qualified for analysis of overall, tibial, and femoral malalignment, whereas 6 films were

Discussion

The main finding in this prospective multicenter study is a significant and clinically relevant association between medial overhang and a 1 Y KOOS pain outcome <70 with an OR of 0.46. This demonstrates that postoperative medial overhang may lead to a 54% reduced chance for entering an acceptable pain (KOOS >70) category 1 year after surgery when receiving a TKA. A total of 18% were observed with medial overhang in this study.

This study is the first to evaluate overhang and malalignment in

Conclusion

In this prospective multicenter study, a significant association was shown between medial overhang and a 1 Y KOOS pain <70, demonstrating a 54% reduced chance for entering an acceptable pain category 1 year after surgery if medial overhang is present after receiving a TKA.

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Undersizing the Tibial Baseplate in Cementless Total Knee Arthroplasty has Only a Small Impact on Bone-Implant Interaction: A Finite Element Biomechanical Study
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Citation Excerpt :
Our results suggest that because the load transfers mostly through the posterior aspect of the implant during stair ascent, the limited support provided by the thin anterior cortex is likely not a key factor for the risk of component subsidence during this activity. Furthermore, maximizing coverage to achieve cortical support may risk implant overhang, which has been related to increased pain and reduced function after TKA [20,21]. In this regard, our results suggest that sub-optimal coverage may not be as critical as previously thought, especially if the baseplate is supported by stiff bone.
The tibial component in total knee arthroplasty (TKA) is often chosen to maximize coverage of the tibial cut, which can result in excessive internal rotation of the component. Optimal rotational alignment may require a smaller baseplate with suboptimal coverage that could threaten fixation. We asked: “does undersizing the tibial component of a cementless TKA to gain external rotation increase the risk of bone failure?”
We developed computational finite element (FE) analysis models from the computed tomography (CT) scans of 12 patients scheduled for primary TKA. The models were implanted with a cementless tibial baseplate that maximized coverage and one or two sizes smaller and externally rotated by 5°. We calculated the risk of bone collapse under loads representative of stair ascent.
Undersizing the implant increased the area at risk of collapse for eight patients. However, the area at risk of collapse for the undersized implant (range, 5.2%-16.4%) was no different (P = .24) to the optimally sized implant (range, 4.5%-17.9%). The bone at risk of collapse was concentrated along the posterior edge of the implant. The area at risk of collapse was not proportional to implant size, and for four subjects undersizing the implant actually decreased the area at risk of collapse.
While implants should maximize coverage of the tibial cut and seek support on dense bone, undersizing the tibial component to gain external rotation had minimal impact on the load transfer to the underlying bone. This FE analysis model of a cementless tibial baseplate may require further validation and additional studies to investigate the long-term biomechanical effects of undersizing the tibial baseplate. In conclusion, while surgeons should strive to use the appropriate tibial baseplate for each patient, our model identified only minor biomechanical consequences of undersizing the implant for the immediate postoperative bone-implant interaction and implant subsidence.
Do Knee Osteoarthritis Patterns Affect Patient-Reported Outcomes in Total Knee Arthroplasty? Results From an International Multicenter Prospective Study With 3-Year Follow-Up
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All OA gradings were performed by 1 external orthopedic surgeon who was not involved with the TKA surgeries and who was blinded to study population characteristics except for geographical location. Postoperative and 1 year radiographs were graded for overall component malalignment vs no component malalignment, and medial overhang vs other overhang type/no overhang [21]. The study population was described according to the 6 compartmental OA groups, age, gender, body mass index (BMI) [22], preoperative Charnley score, and overall component malalignment vs no component malalignment.
The aim of this multicenter study is to answer (1) Does patellofemoral osteoarthritis (OA) affect preoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) scores in total knee arthroplasty (TKA)? and (2) Do different OA patterns affect preoperative and postoperative KOOS scores in TKA?
This international, multicenter prospective study examined 384 TKA patients. Compartmental OA was divided into (1) medial, (2) medial + patellofemoral, (3) lateral, (4) lateral + patellofemoral, (5) medial + lateral (bicompartmental), and (6) medial + lateral + patellofemoral (tricompartmental), based on preoperative anterior-posterior and lateral ± skyline radiographs with Kellgren-Lawrence grade III-IV and joint space width <2.5 mm. KOOS was collected preoperatively, 1 year postoperatively, and 3 years postoperatively. Higher KOOS score represented better clinical state, for example, higher KOOS Pain score indicated less pain.
Patellofemoral OA had no effect on preoperative KOOS scores (P > .15). Compared to medial ± patellofemoral OA patients, bicompartmental/tricompartmental OA patients had less preoperative pain (KOOS Pain 7.4, P = .03) and higher daily function (KOOS-ADL [Activities of Daily Living] 7.1, P = .05), and higher 1-year postoperative daily function (KOOS-ADL 9.2, P = .03) and sports activity (KOOS Sports & Recreation Function 15.0, P = .04), while lateral ± patellofemoral OA patients had more symptoms (KOOS-Symptoms 7.0, P < .01), more pain (KOOS-Pain 7.5, P = .01), lower daily function (KOOS-ADL 9.3, P < .01), and lower quality of life (KOOS-QOL 9.0, P = .04), at 3 years postoperatively.
Patellofemoral OA does not affect medial ± lateral OA patients’ preoperative KOOS scores, challenging the importance of patellofemoral OA in TKA. Lateral ± patellofemoral OA patients have lower postoperative KOOS scores than medial/more progressed compartmental OA patients, indicating that patients with less common OA patterns present with unique surgical challenges. Further development of indications for and correct timing of TKA surgery in different patient subgroups is needed.
Agreement in component size between preoperative measurement, navigation and final implant in total knee replacement
2019, Journal of Orthopaedic Translation
Citation Excerpt :
Incongruity between the sizes of prosthetic components and bone structure has been considered a potential cause of pain and limitation of postoperative mobility. Anteroposterior oversizing of the tibial tray [3,4] or presence of a medial overhang, seen in 20% of cases in some series [5], is associated with pain, decreased mobility, and loss of function after implantation [6]. Preoperative radiographic planning is currently considered indispensable for an adequate procedure and to achieve better clinical and functional results after TKR [7].
One of the possible causes of dissatisfaction reported by many patients after total knee replacement (TKR) is the lack of agreement between component size and bone structure. To avoid this complication and facilitate the procedure, preoperative planning with digitized templates is recommended. Surgical navigation indicates the best position and the most adequate size of arthroplasty and may therefore replace preoperative radiographic measurement. The objective of the study was to check agreement between the sizes of TKR components measured before surgery with digitized templates, the size recommended by the navigation and sizes actually implanted.
In 103 patients scheduled for TKR, preoperative full-limb radiography was performed to measure the mechanical and anatomical axes of the limb, femur and tibia. The most adequate size of the femoral and tibial components was planned by superimposing digitized templates. The size recommended in navigation and the size of the finally implanted components were also recorded.
A high level of agreement was found between the sizes of femoral and tibial components measured by X-rays and in navigation (0.750 and 0.772, respectively) (intraclass correlation and Cronbach's alpha). Agreement between the sizes recommended by X-rays and navigation and those finally implanted was 0.886 for the femur and 0.891 for the tibia. Agreement levels were not different in cases with prior deformities of limb axis.
The high level of agreement found in component sizes between radiographic measurement with digitized templates and navigation suggests that preoperative X-ray measurement is not needed when navigation is used for placement of implants during TKR.
Computer-assisted surgery may avoid preoperative measurement with templates in TKR.
The value of postoperative prosthesis alignment and patellar height measurements on standard X-rays after Total Knee Arthroplasty: Does it relate to knee function after 5 years?
2019, Knee
Citation Excerpt :
Mediolateral tibial component mismatch was found not to influence knee function after 5 years in the current study. Previous literature reports conflicting results [53], more recent studies show mediolateral overhang to be associated with worse function after 1 year [54,55] and one other study describes no differences in knee function after 5 years [56] This could be explained due to inadequate determination of the location of over-underhang (side-specification), resulting in pooling of data and subsequently possible diluted p-values. Post-arthroplasty follow-up using short-leg radiographs is currently standard clinical practice in most European orthopedic clinics due to lower costs and capability to identify crude anomalies.
The purpose of this retrospective cohort study was to investigate the influence of parameters of malalignment on knee function 5 years post TKA and, additionally, to explore alterations in patellar height after TKA.
All 661 patients undergoing TKA between 2010 and 2011 were considered for inclusion. Preoperative and 1-year postoperative short-leg radiographs were assessed for malalignment parameters: coronal tibial angle (cTA), sagittal tibial angle (sTA), femoral flexion angle (FFA) and mediolateral tibial mismatch. Patellar height was measured using the modified Insall-Salvati ratio. We determined improvements in knee function utilizing the Knee Society Score (Function score, KSS-F), Oxford Knee Score (OKS) and Algofunctional index (AI). Influences of malalignment parameters were analyzed univariate and selected (p < 0.10) for multivariate linear regression analysis. Inter-observer reproducibility was assessed by test–retest analysis of 30 randomly selected radiographs and calculation of an intra-class correlation coefficient (ICC) for all radiographic parameters.
Three-hundred and four patients were included. Multivariate regression showed degrees of cTA malalignment to be significantly associated with only the KSS-F (β = − 3.52). Correction of coronal deformity was stronger associated with knee function (KSS-F β = 2.81; AI β = − 0.36). Patellar height was significantly reduced after TKA (1.51 vs 1.44). Decrease of patellar height was weakly associated with the OKS (β = 10.69). ICC scores were: cTA 0.81, sTA 0.57, IS 0.72, FFA 0.75.
Postoperative coronal tibial plate alignment and correction of preoperative coronal deformity are associated with improved knee function 5 years post TKA. Decrease in patellar height was weakly associated with knee function. Short-leg radiography can be a sufficient screening tool for prosthesis alignment.
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: Funding: The authors received no funding for this specific study. Data collection for the cohort of patients included in this study, investigating the outcome of TKA, has been supported with funding from Zimmer Biomet.

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2017.12.027.

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Primary ArthroplastyMedial Overhang of the Tibial Component Is Associated With Higher Risk of Inferior Knee Injury and Osteoarthritis Outcome Score Pain After Knee Replacement

Abstract

Background

Methods

Results

Conclusion

Section snippets

Method

Results

Discussion

Conclusion

Knee

J Arthroplasty

J Arthroplasty

Osteoarthritis Cartilage

Knee

Knee

J Arthroplasty

Evaluation of alignment in total knee arthroplasty: a prospective study

Eur J Orthop Surg Traumatol

Tibial component positioning in total knee arthroplasty: bone coverage and extensor apparatus alignment

Knee Surg Sport Traumatol Arthrosc

Predicting the effect of tray malalignment on risk for bone damage and implant subsidence after total knee arthroplasty

J Orthop Res

Tibial component coverage based on bone mineral density of the cut tibial surface during unicompartmental knee arthroplasty: clinical relevance of the prevention of tibial component subsidence

Arch Orthop Trauma Surg

What is the optimal alignment of the tibial and femoral components in knee arthroplasty?

Acta Orthop

The effect of alignment and BMI on failure of total knee replacement

J Bone Joint Surg

Knee injury and osteoarthritis outcome score (KOOS)

J Orthop Trauma

Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure

J Orthop Sports Phys Ther

I can’t get no satisfaction after my total knee replacement: rhymes and reasons

Bone Joint J

Evaluation of patients with a painful total knee replacement

J Bone Joint Surg Br

Primary Arthroplasty
Medial Overhang of the Tibial Component Is Associated With Higher Risk of Inferior Knee Injury and Osteoarthritis Outcome Score Pain After Knee Replacement