The posterolateral upslope of a low-conforming insert blocks the medial pivot during a deep knee bend in TKA: a comparative analysis of two implants with different insert conformities

Purpose: Tibial insert conformity in total knee arthroplasty (TKA) is of interest due to the potential effect on tibiofemoral kinematics. This study determined differences in anterior-posterior movements of the femoral condyles, pivot locations, and internal tibial rotation in different arcs of flexion for two implants with different insert conformities in kinematically aligned TKA.

Methods: Twenty-five patients treated with a medial and lateral low-conforming, posterior cruciate ligament (PCL) retaining (LC CR) implant followed by a medial ball-in-socket and flat, lateral PCL sacrificing (B-in-S CS) implant in the contralateral knee underwent single-plane fluoroscopy during a deep knee bend. Analysis following 3D-to-2D image registration determined tibiofemoral kinematics and patients completed validated outcome scores for both knees.

Results: The mean follow-up of 1.6 ± 0.4 years for the knee with the B-in-S CS implant was shorter than the 2.7 ± 1.2 years for the LC CR implant. From 0º to 30º of flexion, a medial pivot occurred with the tibia rotating internally approximately 5º with both implants. From 30º to 90º, the pivot remained medial and internal rotation increased to 10º with the B-in-S CS implant. In contrast, neither femoral condyle moved more than 1 mm with the LC CR implant from 30º to 60º, but from 60º to 90º degrees, a lateral pivot occurred and internal rotation increased. Internal rotation of the tibia on the femur from 0° to maximum flexion occurred about a medial pivot similar to the native knee for the B-in-S CS implant and was 4.5° greater than that of the LC CR implant (10.4° vs 5.9°). There was no difference in the median patient-reported outcome scores between implant designs.

Conclusions: Tibial insert conformity is a primary determinant of a medial or lateral pivot during a deep knee bend. One explanation for the transition from a medial to lateral pivot between 30º and 60º with the LC CR implant is the chock-block effect of the insert's posterolateral upslope which impedes posterior movement of the lateral femoral condyle. Because there is no posterolateral upslope in the insert of the B-in-S CS implant, the tibia pivots medially throughout flexion similar to the native knee.

Level of evidence: Level III.