KNEE ARTHROPLASTY

Biomechanics of the knee replacement patients gain a functional range of motion that is
satisfactory, yet the kinematic patterns of these knees can be

joint, as they relate to highly variable. A typical range of motion reported in 2016 is
between 115 and 125 , yet only 73% of knee replacement pa-
tients report a functional outcome that is satisfactory to them.1
arthroplasty Reported reasons for dissatisfaction are persistent pain, insta-
bility, clicking, swelling and “my knee just doesn’t feel like my
Sumesh M Zingde old knee”.
John Slamin At present, most implant manufacturers are focused on
improving patient satisfaction, as we believe that survivorship
cannot be appreciably improved over what the literature is
Abstract presently reporting. Some designers are attempting to improve
satisfaction by making small improvements to their existing
This article covers the current understanding of human knee biome-
design, such as modifying the sagittal ‘J’ curves. Others are
chanics and how these data are used in the assessment and develop-
focussing on preserving more anatomic structures, such as the
ment of knee replacement implants. Extensive and well corroborated
anterior cruciate ligament. Most implant manufacturers have
data is available to the surgeon and engineer implant designer to aid
moved to increase the sizes of implants available in an attempt to
in the design of new implant systems. The forces acting on the
reduce implant overhang and underhang, which has been re-
human knee joint have been measured experimentally from both
ported as a source of potential pain.2
external methods and permanently implanted telemetric devices. Mo-
We will review what has been published in the literature for
tions of the knee are well understood for both the healthy knee as well
kinematic outcomes of cruciate retaining total knee replacement,
as all commercially available total knee replacements today. Implant
posteriorly-stabilized total knee replacements and mobile
designers are now compelled to use these data in the design and
testing of new implant systems.
bearing knee replacements. We will also discuss how a new
approach to cruciate retaining knee design is dispelling the
We now have 45 years in the modern age of knee replacement, with
notion that cruciate retention knee design produces paradoxical
many lessons learned to-date, and repeating mistakes can now be
femoral rollback.
avoided with just a fundamental understanding of the available pub-
lished data on biomechanics and motion of the knee joint. To-date
most implant designers have settled upon an averaging approach to Introduction to kinematics
the design of implant systems. We have now entered into an age Arthritic degeneration caused by arthritis is one of the most
where it is possible to customize implants for each individual patient commonly reported musculoskeletal problems in the older pop-
yet respect all of the hard learned lessons of the past 45 years. ulation. For end-stage arthritis, the most favoured treatment
Keywords knee biomechanics; knee implant design; knee kine- modality is for the patient to undergo a Total Knee Replacement
matics; total knee replacement (TKR). The primary goal of TKR is to relive pain and restore
function. Over the years there has been a trend towards TKRs
being implanted in younger, more active patients. This brings a
Introduction renewed focus on functional ability and patient satisfaction after
TKR surgery. At least 150 TKA designs exist in the world market
In this paper we set out to explore how various different
today, with advances by surgeons and engineers that aim to
approaches to implant design can influence the kinematic
simulate the geometry and behaviour of a healthy knee joint.3
outcome of knee replacement surgery, and conversely, how our
The differences in these designs are based on factors such as
increasing knowledge in all aspects of biomechanics has influ-
condylar geometry, bearing mobility, ligament preservation vs
enced implant design. We hypothesize that kinematic function is
substitution, and fixation methods.4 In order to better understand
directly related to patient outcome. In the early days of knee
the differences between these design philosophies and their
replacement surgery the goal was to relieve the pain from the
impact on kinematics of TKRs post-surgery, it is important to
disease. At that time, we really had a very poor understanding of
understand the kinematics of the normal knee.
the true biomechanics and kinematics of the human knee.
Functional motion of the knee was rarely achieved. As we gained
Normal knee kinematics
more experience in both the surgical approach, as well as the
design philosophy, we began to realize a range of motion that There are a multitude of studies that have investigated kine-
was acceptable, yet not optimal. In 1980, a range of motion of matics of the normal knee, which involve different methods,
105 was considered an average outcome. Today, most knee such as cadaveric testing using knee simulators,5 non-invasive
skin markers,6,7 invasive bone pins,8 in-vivo roentgen stereo-
photogrammetric analyses (RSA),9 externally worn goniometric
devices,10 and fluoroscopic techniques.11,12
Sumesh M Zingde Ph.D. Clinical Manager, ConforMIS Inc., Bedford, Using these techniques, there is a general agreement in the
MA 01730, USA. Conflicts of interest: none declared. scientific community on how a normal knee moves. At full
John Slamin Associates in Mechanical Design Engineering Senior Vice extension, the femur is internally rotated with respect to the
President of Product Engineering, ConforMIS Inc., Bedford, MA tibia, and is located anterior to the mid-point of the tibial
01730, USA. Conflicts of interest: none declared. plateau. As the knee flexes, the lateral condyle of the femur

ORTHOPAEDICS AND TRAUMA 31:1 1 Ó 2016 Published by Elsevier Ltd.

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 KNEE ARTHROPLASTY

consistently translates posteriorly on the lateral tibial plateau the implant design to deal with soft tissue structures. The second
with increasing flexion. The medial condyle on the other hand classification can be made based on the implant design philos-
experiences a less consistent motion pattern that includes pos- ophy and geometry. As far as soft tissue structures are con-
terior translation and anterior slide during knee flexion. This cerned, TKRs can be divided into:
leads to a reduced overall posterior translation of the medial  Bi-Cruciate Retaining (BCR): both cruciate ligaments are
condyle on the medial tibial plateau from full extension to retained.
maximum knee flexion. The larger magnitude of the lateral  Posterior Cruciate Retaining (PCR): the ACL is sacrificed
femoral translation, when coupled with a lesser translation of but PCL is retained.
the medial femoral translation, leads to the femur externally  Posterior Cruciate Stabilizing (PS): both cruciate ligaments
rotating with respect to the tibia as the knee flexes. are sacrificed and the implant provides for mechanical
Previous studies on cadaveric knees have revealed that the stabilization for the PCL.
lateral femoral condyle rolls back an average of 18 mm from full  Bi-cruciate Stabilizing (BCS): both cruciate ligaments are
extension to full flexion while the medial femoral condyle rolls sacrificed and the implant provides for mechanical stabi-
back only 1.5 mm.5 These results have been supported by in-vivo lization for the ACL and PCL.
studies that indicate a similar trend, with the average lateral Over the years, studies conducted to investigate TKR kine-
femoral condylar rollback for weight-bearing flexion being 21 matics have shown differing results based on the type of implant
mm and that for the medial femoral condyle being 1.9 mm.13 In a used. Bi-cruciate retaining knees have been shown to provide
study that analysed the kinematics of 104 normal knees, Mueller kinematic patterns that better approximate normal motion,
et al. found that all 104 (100%) subjects with a normal knee though less in magnitude, when compared to PCR and PS TKA.
while performing a weight-bearing deep knee bend (DKB) Mueller et al., in a multi-centre analysis of more than a 1000
experienced posterior motion of the lateral condyle, whereas 102 TKRs, analysed 34 BCR knees. They found that 91% of patients
of 104 (98%) subjects experienced posterior motion of the medial with a BCR TKR experienced posterior motion of their lateral
condyle.14 This shows that though the magnitudes of femoral condyle and 88% had posterior motion of their medial condyle.14
translations vary between the medial and lateral compartments The magnitudes of rollback and axial rotation were found to be
of the knee, the consistency of posterior rollback with increasing lower than normal knees. It can be hypothesized that the relative
knee flexion is prevalent in both compartments. This asymmetric similarity between the kinematics of the normal knee and the
rollback leads the femur to externally rotate on the tibia as the BCR TKR is due to the retention of the ACL, which provides
knee flexes. Typical magnitudes of axial rotation have been better stability and proprioception, thus leading to better kine-
found to be around 21 from full extension to maximum knee matic function. However, one concern with BCR TKR is the
flexion in cadaveric studies5 and 17.8 in in-vivo studies.14 limited indications for use in patients. Typically, with advanced
The causes for these complex motion patterns are many. One arthritis, the ACL is attenuated or is not fully functional. Also, the
primary factor is the condition of the soft tissues surrounding the condition of the ACL is not entirely apparent by examining ra-
cruciate and collateral ligaments in conjunction with the differing diographs taken prior to surgery. The surgery itself is more
structures of the lateral and medial meniscus. In order to un- challenging and some outcome studies have shown higher re-
derstand the influence of the anterior cruciate ligament on knee operation and revision rates after BCR surgery.15 This limits
kinematics, Dennis et al. conducted in-vivo testing of 10 normal the scope of the utilization of these variants.
knees and five ACL-deficient knees. They found that although the Traditional PCR TKRs have increased indications for use, with
ACL-deficient knees do exhibit similar motion patterns to the roughly 90% of patients being candidates for this type of implant,
normal knee, their magnitudes differ.13 This study shows the although the market distribution for CR implants is very
effect the ACL plays on knee kinematics. Another reason is the different. Studies investigating the kinematics of PCR TKR have
geometry of the lateral and medial femoral condyles, where each shown that the implants do not replicate normal knee motion.
femoral condyle has varying sagittal radii of curvature Instead, they exhibit paradoxical anterior femoral translation
throughout the flexion arc. In addition, the sagittal radii of the during deep knee flexion16 and reverse axial rotational pat-
lateral and medial femoral condyles vary considerably with each terns,17 a phenomenon that is contradictory to normal knee
other, exhibited by the distal offset between them when viewed motion. In a multicenter study that investigated TKR kinematics
in the coronal plane, and a posterior offset in the deep flexion of 33 different TKR designs, Dennis et al. found anterior slide in
arc, when viewed in the sagittal plane. some PCR TKRs to be as high as 6.4 mm on average. They also
Since all TKR surgeries involve the alteration of the soft tis- found that the rate of anterior slide during a deep knee bend
sues surrounding the knee joint, the key to restoring ‘normal- varied considerably, with some designs exhibiting an anterior
like’ patterns post TKR surgery hinges on the nature and slide 80% of the time. This resulted in altered axial rotation
magnitude of these alterations. Additionally, similar to the role patterns.
played by femoral geometries of the native knee, geometries of Paradoxical anterior slide during deep knee flexion may lead
the TKR design also play an important role in determining TKR to several undesirable effects. Primary among them is locating
kinematics. the femur more centrally on the tibial plateau in deeper flexion.
This leads to impingement of the posterior condyles of the femur
on the posterior tibial lip, hence preventing further flexion and
Total knee replacement kinematics
reducing range of motion.16,18 Rapid anterior sliding motion can
The influences upon TKR kinematics can be broadly classified also lead to increased wear of the polyethylene.19 Reserve axial
into two groups. The first classification is based on the ability of rotation patterns can lead to patellofemoral instability.17

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 KNEE ARTHROPLASTY

PS and BCS TKR, on the other hand, have been shown to demonstrate any difference in terms of range of motion, knee
provide better rollback and increased range of motion when scores and survivorship23e25,4 A multicenter study conducted by
compared to PCR TKR. These types of implant also increase the Wasielewski et al.26 on 527 mobile bearing TKAs found that
indications for use and can cover nearly all types of patient. rotational parameters were comparable with the results reported
Dennis et al., in their multicenter study, found that PS TKR for fixed bearing TKA by Dennis et al.17
experienced rollback of the lateral and medial condyles more Femoral geometry in TKR varies considerably between
than 90% of the time during deep knee bend.16 Mueller et al., in implant designs. Some designs incorporate a single sagittal
their multicenter study, corroborated those results and also radius in both femoral condyles. Others have three or four
investigated BCS TKR, where they found 100% of patients different radii through the flexion arc, with reducing radii in
experienced rollback patterns. They also found that magnitudes deeper flexion. Kinematic studies that have investigated TKR
of rollback for the BCS TKR were similar to the normal knee with these geometric variations have found that TKR kinematics
while rollback magnitudes of PS TKR were lower than the BCS do not replicate normal knee motion. Apart from exhibiting
TKR but higher than PCR TKR.14 paradoxical anterior slide and reverse axial rotation, TKRs have
The improved rollback in deeper flexion with these implants shown instances of lateral femoral condylar lift-off. Femoral
has been attributed to the engagement of the cam and post condylar lift-off creates excessive loads on the polyethylene
mechanism. Once the cam and post engages, it drives the femur bearing, risking premature polyethylene wear.27
posteriorly, thus enabling better rollback when compared to their A recent study by Grieco et al. investigated TKR kinematics of
PCR TKR counterparts. However, this has led to the suggestion 50 patients with either single radius TKR or a multi radius TKR
that the rollback seen in PS and BCS TKRs is due to the ‘guided with asymmetric condyles. They found that during deep knee
motion’ provided by the cam-post engaging, which leads to higher bend the single radius knee experienced only 0.43 mm of pos-
rates of implant failure due to cam-post wear and fracture. Also, terior rollback of the lateral condyle, coupled with a significant
when looking at early and mid-flexion, it has been found that PS anterior slide of 3.51 mm of the medial condyle. The multi-radius
and BCS TKR designs have experienced similar kinematic pat- knee had similar lateral rollback and minimal anterior slide of the
terns as those designs that lacked a cam and post mechanism. medial condyle.28 Multicenter studies conducted on multi-radius
This has been attributed to the fact that the cam and post mech- knees have demonstrated similar results with most multi-radius
anism do not engage during lesser flexion activities such as gait. designs.13,15
Zingde et al. looked at cam-post interaction in BCS and PS In summary, TKRs have been shown to demonstrate variable
TRK and found a wide variation between implant designs as to kinematic patterns based on the nature of ligament retention as
when the cam and post engage.20 The contact angle varied from well as with different design philosophies. Most traditional TKRs
an average of 32 up to 97 . Banks et al., reported on the cam and have repeatedly been shown to exhibit kinematic patterns that
post function in five knees with a PS TKR.21 Their study esti- are atypical to the normal knee. TKRs with mechanical stabili-
mated cam-post engagement to occur at 40 of flexion during a zation do provide better kinematic results than TKRs that retain
step-up manoeuvre. Suggs et al., in their paper, investigated the the PCL. Geometric variations do not seem to provide an
flexion range at which cam-post engagement occurred during a adequate solution to improving TKA kinematics. The hypothesis
lunge activity for 24 TKAs subjects in-vivo, and reported an is that TKRs with standardized geometries may not be able to
average contact angle of 91.1 , with a range from 69 to 114 .22 accommodate for the wide variations seen in the human
The role of the cam-post mechanism in a BCS and PS TKR is vital anatomy.
to improving the kinematic function of these implants. However,
in the range of flexion prior to cam-post engagement, kinematics
Forces acting upon the human knee
of these implants are primarily driven by the implant geometry,
since both the cruciate ligaments are sacrificed. This increases We now have over 50 years of continuously evolving under-
the role of geometry in facilitating TKR kinematics. standing of the biomechanics of the human knee. Although it is
Implant geometry variations in TKR can be broadly catego- interesting to note that some of the earliest measurements and
rized based on bearing mobility (fixed vs mobile bearing) and the mathematical predictions made by Morrision29 in 1970 have
sagittal curvature of the femoral component (single radius vs J- been largely corroborated by Colwell30 in 2005, with the E-Knee.
curves). Mobile bearing TKRs were designed to reduce contact Morrison made force plate measurements of adult subjects and
stress in the polyethylene insert, thereby reducing wear, and combined this data with film information that provided crude
recreating more ‘normal-like’ knee kinematics. They aim to acceleration information for the limb. These data were then used
decouple the translational and rotational kinematics of the knee in a mathematical model to calculate joint reaction forces at the
during flexion. The mobile bearing enables the rotational knee joint. They predicted that the total joint reaction force acting
component of motion to occur between the polyethylene bearing through the knee is between two and four times the individual’s
and the tibial tray, whilst the translational component occurs on body weight. They also predicted that the majority (no figure
the femoral component and polyethylene articular surface. The reported) of the load was transmitted through the medial
constrained nature of the articular surface aims to increase the compartment.
contact area of the system. However, kinematics, clinical out- Colwell reported the first articular joint replacement device for
comes and survivability between fixed and mobile bearing im- the human knee that could take direct joint reaction compressive
plants have produced similar results. Studies that have compared forces. In his first report on the in-vivo use of this device, he
the performance of the mobile and fixed configurations in the measured forces across the knee for average daily activities to be
same patient have also concluded that the patient does not between two and three times the patient’s weight.31

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 KNEE ARTHROPLASTY

Colwell developed a second generation instrumented tibial come about since publications in the 1998e2002 timeframe
plateau that was capable of not only measuring compressive described the ‘cam and post’ impingement condition. These papers
forces across the knee, but that could also measure shear forces. reported on high tibial wear and deformation when improper
In this study they were able to confirm the compressive forces design resulted in the femoral component imposing deforming
from the first generation device and reported that the maximum loads onto either the anterior or posterior surface of the tibial sta-
shear force measured was 0.3 times the patient’s weight.32 This is bilizing spine.
considerably lower than previous mathematical predictions.33
Component modularity testing
How does this relate to total knee design and Whenever there are modular components that are intended to be
replacement? assembled at the time of surgery, testing of those modular
junctions is indicated. Examples of such interfaces include
In the early years of total knee replacement, when this author, modular tibial bearing surfaces, fixation stems, condylar
Slamin, first became involved with the design of implant sys- augmentation and tibial wedges. In these cases very broad
tems, little was known of the rigours that implants would be guidelines exist and most implant manufacturers have developed
subjected to. There were a few published papers reporting on the their own test methods to validate the safety of their devices. In
theoretical forces that acted upon the knee joint. The range of all cases, the guidelines specifically state that the testing must
motion of healthy patients was well understood, but rarely ach- represent real-world conditions for the testing environment.
ieved with the early implant systems. Biomechanical testing was Additional requirements imposed by the United States Food and
rudimentary at best in the 1975 to 1980 timeframe, and not Drug Agency (FDA) require that all testing be conducted in a
required by the regulating government agencies. As clinical ‘worst case condition’. This additional condition imposed by the
limitations began to be recognized and mechanical failures began FDA is generally interpreted to be the size of the device that
to pile up, we turned to the available biomechanical publications would be subjected to the greatest stress, or the loading condition
and considered how this data can drive design improvements. that would be most likely to cause mechanical failure.
Today, one cannot ethically or practically design a total knee
replacement without intimate knowledge of the published data Tibial contact area and stress
on the forces and kinematics of the human knee. Extensive Since Bartell first taught us that polyethylene wear is directly
testing programs are conducted that use the force and motion related to condylar geometry and conformity, the contact area
data to validate the safety and efficacy of all new implant sys- and stress at the articulating surface has been a standard
tems. Specific examples of how published biomechanical data is biomechanical test for most implant systems.19 This is also an
applied to implant testing follow: area where universal standardized test methods do not exist, and
thus every implant manufacturer has developed their own in-
Implant wear ternal protocols. As in the modularity requirements discussed
When implant wear testing is indicated (typically when a new above, conditions need to be based on actual clinical conditions
polyethylene material is introduced into clinical use), extensive with the added FDA requirement that the ‘worst case conditions’
wear testing is conducted. The forces, motions and duration of be tested. In some cases the worst case could be the largest
the testing are all based on sound experimental data published implant in an implant system because the largest patient would
within the literature. A typical wear test that would be used to logically have the highest body mass, and in some cases it could
gain acceptance by the FDA or a CE certifying body will involve a be the smallest implant in the system, where this device could
minimum of five million cycles, which represents approximately have the smallest contact patch for load distribution.
5 years of normal activity. The loading applied as well as the The list above is not all-inclusive, but it provides the reader a
dynamic motion of the device are described in a document sense of how the current knowledge base for biomechanics of the
referred to as the ISO-14243 standard. human knee does influence the implant design. Each manufac-
turer of knee replacements has a set of additional biomechanical
Cyclic fatigue testing
requirements that is tested for prior to clinical use. These have
Cyclic fatigue testing has been conducted on tibial plateaus for
evolved within each company as they make observations from
many years now. There is an ASTM (American Society for Testing
clinical outcomes as they conduct failure analysis of their own
and Materials) standard or, alternatively, an ISO-14879 standard
implant retrievals.
that can be used to validate a new design. Dynamic fatigue testing
of femoral components has only become routine recently, yet no
The case for customization
agreed upon standard exists at the time of writing. There is an
ASTM standard under development, but curiously it is unrepre- Ligament condition and implant geometry play an important role
sentative of reported failures in the published literature. The in influencing TKR kinematics. Most researchers who have stud-
standard under development calls for a femoral component to be ied TKR kinematics have found them to be unable to consistently
subjected to a collapsing loading condition. This could theoreti- reproduce the kinematic patterns seen in the normal knee. PCR
cally occur if complete bony support was lost on one of the pos- TKRs have shown the tendency to exhibit anterior slide of the
terior condyles. To this author’s knowledge, the test does not femoral condyles. This could be in part due to the inability of the
represent mechanical failures that are reported within the pub- PCL to accommodate for the geometric shapes of traditional TKRs,
lished literature. Cyclic fatigue testing is also required for posterior which are derived from statistical averages and which do not
stabilized implant systems where there is a tibial spine. This has replicate the patient’s native anatomy for which the PCL is

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 KNEE ARTHROPLASTY

conditioned. Mechanical stabilization, as seen in PS and BCS flexion arc. For the PS customized implants, the femoral cam and
TKRs, do provide better rollback, facilitated by the engagement of polyethylene post are designed using a patient-specific method-
the cam and post mechanism. However, kinematics in the flexion ology, which is controlled to enable engagement after 90 of
range prior to cam post engagement have been inconsistent. Also, knee flexion. These design features reproduce the patient’s
the flexion angle at which the cam and post engage is variable native distal and posterior offsets (Figure 2), thus enabling the
between patients and between implant designs. surgeon to reproduce the patient’s joint line during surgery and
One potential solution to these issues could be the use of maintain ligamentous isometry. The tibial tray is designed to
customized, individually made total knee replacements (CIM match the resected surface of the proximal tibia, and is virtually
TKR). CIM TKR are produced to match each patient’s individual aligned to achieve optimal tibial rotation. All implant compo-
anatomy and are available in PCR and PS variants. This is nents are made to achieve optimal shape and fit, without sig-
accomplished by procuring a CT scan of the patient’s lower limb nificant under-coverage or any overhang. The full set of single-
to include the hip centre, the ankle and a detailed scan of the use disposable instrumentation is also generated for each
knee. The CT data is used to generate patient-specific Computer implant.
Assisted Design (CAD) bone models. The implant is then CIM TKRs have the potential to prevent atypical kinematic
designed to match the patient’s anatomy and correct for bony patterns, as seen with traditional TKRs, while enabling more
and alignment related deformities. This results in fully custom- normal-like kinematic patterns. In PCR CIM TKRs, since the
ized femoral and tibial implants. implant is customized to each patient, the geometry of the implant
On the femoral side, three J-curves (Figure 1) are generated is synchronous with the conditioning of the existing soft tissue
for the lateral and medial femoral condyles and the trochlear structures. This reduces the potential for paradoxical motions in
groove that follow the patient’s native J-curves. The femoral the knee during flexion. For PS CIM TKRs, in addition to the
implant is designed to maintain these J-curves while virtually implant geometry being customized, the cam-post mechanism is
correcting for deformities. The polyethylene inserts are designed also designed using a patient-specific methodology. This reduces
to match the femoral J-curves in the sagittal plane through the the dependence of the cam-post interaction to drive rollback. In
the early to mid-flexion arc, prior to cam-post engagement, the
patient-specific geometry stabilizes the knee and enables rollback.
In deeper flexion, the cam-post engages, and provides additional
support to enable rollback in deeper flexion.
Reproducing the native distal and posterior offsets in
conjunction with the patient specific J-curves reduces the need
for ligament releases, thus enabling the knee to be completely
balanced throughout the range of motion. This increases stabil-
ity, especially in the early to mid-flexion range, thus reducing the
chances of condylar lift-off.
Early studies that have investigated the kinematics of the CIM
TKR have shown promising results. Patil et al. conducted an
analysis of 18 matched cadaver limbs. They assigned half to the
CIM groups and half to a traditional PCR TKR group. All 18 limbs
were first analysed on a knee simulator to determine their native
kinematics. Post implantation, each limb was re-tested to deter-
mine TKR kinematics. Results showed that kinematic motion
Figure 1 Three patient-specific ‘J’ curves are derived from the femoral
bone model, representing the medial, trochlear and lateral profiles. was significantly closer to normal among the CIM TKR limbs for

Figure 2 The CIM TKR, as illustrated in planning stage derived from CT data, preserves the patient’s
natural distal and posterior offsets.

ORTHOPAEDICS AND TRAUMA 31:1 5 Ó 2016 Published by Elsevier Ltd.

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 KNEE ARTHROPLASTY

femoral rollback, active tibiofemoral adduction and passive customized individually made knee replacement in the near
varusevalgus laxity, when compared to traditional PCR TKR future as more compelling evidence is published. A
limbs.34 They concluded that CIM TKR generates kinematic
patterns more closely resembling normal knee kinematics when
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Discussion and summary
9 Banks SA, Hodge WA. Accurate measurement of three-
At present, our understanding of how the human knee works is dimensional knee replacement kinematics using single-plane
fairly complete. We have observable evidence from Colwell on fluoroscopy. IEEE Trans Biomed Eng 1996 Jun; 43: 638e49.
exactly what forces are acting upon the knee during daily activ- 10 Mahfouz MR, Hoff WA, Komistek RD, Dennis DA. A robust
ities. The range of motion has been studied extensively by method for registration of three-dimensional knee implant models
several investigators, with well documented kinematics for all to two-dimensional fluoroscopy images. IEEE Trans Med Imaging
types of total knee replacements. Furthermore, we can now use 2003 Dec; 22: 1561e74.
this kinematic and force data to continue to improve the reli- 11 Dennis DA, Mahfouz MR, Komistek RD, Hoff W. In vivo determi-
ability of new implant systems. nation of normal and anterior cruciate ligament-deficient knee
What has become clear to these authors is that no matter kinematics. J Biomech 2005 Feb 28; 38: 241e53.
which of the historical implant systems one studies, they all have 12 Mueller J, Komistek RD, Dennis DA. Kinematics of the implanted
shortcomings with respect to kinematic function. Approximately and non-implanted knee. Insall & Scott surgery of the knee. 5th
65% of all TKRs conducted today are of the posteriorly-stabilized edn. Philadelphia, PA, USA: Churchill Livingstone, 2012.
type. This is in part due to studies cited here that report that more 13 Christensen JC, Brothers J, Stoddard GJ, et al. Higher frequency
normal kinematics can be achieved with this type of device. of reoperation with a new bicruciate-retaining total knee arthro-
However, the data also shows that up to 27% of patients are not plasty. Clin Orthop 2016 Apr; 4: 1e8.
satisfied with their knee replacement. This suggests that more 14 Dennis DA, Komistek RD, Mahfouz MR, Haas BD, Stiehl JB.
normal motion resulting from the standard PS design may not be Conventry Award Paper: multicenter determination of in vivo
adequate. Patil demonstrated that the individual kinematic kinematics after total knee arthroplasty. Clin Orthop 2003 Nov 1;
pattern of a cadaveric limb can be more closely duplicated with a 416: 37e57.
customized total knee when compared to a standard TKR. This is 15 Dennis DA, Komistek RD, Mahfouz MR, Walker SA, Tucker A.
significantly different from the studies reported above for stan- A multicenter analysis of axial femorotibial rotation after total knee
dard knee replacements, where results are averaged for all limbs arthroplasty. Clin Orthop 2004 Nov 1; 428: 180e9.
studied. 16 Haas BD, Komistek RD, Stiehl JB, Anderson DT, Northcut EJ.
In closing, the future for knee replacement patients is very Kinematic comparison of posterior cruciate sacrifice versus
positive, with new innovations coming into clinical use contin- substitution in a mobile bearing total knee arthroplasty.
uously. One should expect to see a broader acceptance of the J Arthroplasty 2002 Sep 30; 17: 685e92.

ORTHOPAEDICS AND TRAUMA 31:1 6 Ó 2016 Published by Elsevier Ltd.

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 KNEE ARTHROPLASTY

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ORTHOPAEDICS AND TRAUMA 31:1 7 Ó 2016 Published by Elsevier Ltd.

þÿDownloaded for Manuel Azael Rodrÿýguez Cigala (manuel_azael_rc@hotmail.com) at Autonomous University of Guadalajara from ClinicalKey.com by Elsevier on October 13, 2020.
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