ON THE UNRELIABILITY OF COLLATERAL STABILITY ASSESSMENT IN KNEE ARTHROPLASTY WITH THE KNEE LOCKED IN SCREW HOME POSITION: A KINETIC - KINEMATIC MECHANICAL STUDY

Soft tissue balancing in total knee replacement may well be the determining factor in raising the fair patient satisfaction. The development of intelligent implants allows quantification of reactive loads to applied pressures. This can be tested in dynamic mode such as heel push test at surgery, or in static mode such as when testing for varus/valgus (VV) laxity of the collateral ligaments of the knee. We postulate that a well-balanced knee will have comparable if not equal load distribution across compartments in dynamic loading. When tested for laxity, we anticipate an equal or comparable response to VV applied loads under physiologic load range of 10–50N. This study sought to analyze the relationship between the kinematic (joint motion) and kinetic (force) effects to VV testing in the 0–15 degrees range of flexion. One goal was to demonstrate that testing the knee in locked extension (Screw Home effect) is unreliable and should be abandoned in favor of the more reliable VV testing at 10–15 degrees of flexion. This is a preliminary cadaveric study utilizing data from two hemibodies. The pelvis was fixed in a custom test rig with open or closed chain lower leg testing capability along a sliding rail with foot VV translational. Forces were applied at the malleoli with a wireless hand held dynamometer. Kinematic analysis of the hip-knee-ankle (HKA) tibiofemoral angle was derived from a commercial navigation system with mounted infrared trackers. Kinetic analysis was derived from a commercially available sensor imbedded in a tibial trial liner. Balance was optimized by conventional methods with the use of the sensor feedback until loads were roughly symmetrical and VV testing yielded symmetrical rise in opposite compartments. The VV testing was then performed with the knees locked at the femoral side in axial rotation and translational motion in any plane. Sagittal flexion was pre-set at 0, 10, and 15 degrees and progressive load was applied. Results From the graphs one can observe significant differences between VV testing at 0 degrees (locked Screw Home), 10 degrees, and 15 degrees of flexion. The shaded area corresponds to the common range of VV stress testing loading pressure, typically less than 35N. The HKA deviates from neutrality no sooner than by the middle of the physiologic test zone. By 35N, the magnitude of the effect is also much less than that observed at 10 and 15 degrees (unlocked from Screw Home). From the kinetic analysis one can also note the significant difference in the High-Low spread throughout the testing range of applied pressure. If the surgeon tests in the low range of applied loads, he/she may not observe the kinematic joint opening effect. The kinetic effect seems more reliable as sensed loads are detectable earlier on. It is clear however that testing at 10–15 degrees offers a much better sensitivity to the VV laxity or stiffness as exemplified in the bottom portions of the figure. Therefore testing in locked Screw Home full extension may lead to underestimation of the true coronal laxity of the joint.