Maximizing Tibial Coverage Is Detrimental to Proper Rotational Alignment

• Published in: Clinical orthopaedics and related research Vol. 472; no. 1; pp. 121 - 125
• Main Authors: Martin, Stacey, Saurez, Alex, Ismaily, Sabir, Ashfaq, Kashif, Noble, Philip, Incavo, Stephen J.
• Format: Journal Article
• Language: English
• Published: Boston Springer US 01-01-2014; Lippincott Williams & Wilkins Ovid Technologies
• Subjects: Arthroplasty, Replacement, Knee - instrumentation; Arthroplasty, Replacement, Knee - methods; Biomechanical Phenomena - physiology; Computer Simulation; Conservative Orthopedics; Humans; Knee; Knee Joint - diagnostic imaging; Knee Joint - physiology; Knee Joint - surgery; Medicine; Medicine & Public Health; Orthopedics; Radiography; Range of Motion, Articular - physiology; Rotation; Sports Medicine; Surgery; Surgical Orthopedics; Symposium: 2013 Knee Society Proceedings; Tibia - diagnostic imaging; Tibia - physiology; Tibia - surgery; Rotational Position; Rotational Alignment; Total Knee Arthroplasty; Tibial Component; Tibial Tubercle
• ISSN: 0009-921X; 1528-1132
• DOI: 10.1007/s11999-013-3047-y

Background
Traditionally, the placement of the tibial component in total knee arthroplasty (TKA) has focused on maximizing coverage of the tibial surface. However, the degree to which maximal coverage affects correct rotational placement of symmetric and asymmetric tibial components has not been well defined and might represent an implant design issue worthy of further inquiry.
Questions/purposes
Using four commercially available tibial components (two symmetric, two asymmetric), we sought to determine (1) the overall amount of malrotation that would occur if components were placed for maximal tibial coverage; and (2) whether the asymmetric designs would result in less malrotation than the symmetric designs when placed for maximal coverage in a computer model using CT reconstructions.
Methods
CT reconstructions of 30 tibial specimens were used to generate three-dimensional tibia reconstructions with attention to the tibial anatomic axis, the tibial tubercle, and the resected tibial surface. Using strict criteria, four commercially available tibial designs (two symmetric, two asymmetric) were placed on the resected tibial surface. The resulting component rotation was examined.
Results
Among all four designs, 70% of all tibial components placed in orientation maximizing fit to resection surface were internally malrotated (average 9°). The asymmetric designs had fewer cases of malrotation (28% and 52% for the two asymmetric designs, 100% and 96% for the two symmetric designs; p < 0.001) and less malrotation on average (2° and 5° for the asymmetric designs, 14° for both symmetric designs; p < 0.001).
Conclusions
Maximizing tibial coverage resulted in implant malrotation in a large percentage of cases. Given similar amounts of tibial coverage, correct rotational positioning was more likely to occur with the asymmetric designs.
Clinical Relevance
Malrotation of components is an important cause of failure in TKA. Priority should be given to correct tibial rotational positioning. This study suggested that it is easier to balance rotation and coverage with asymmetric tibial baseplates; clinical research will need to determine whether the observed difference affects patellar tracking, loosening rates, or the likelihood of revisions after TKA.