Tibia-first, gap-balanced patient-specific alignment restores bony phenotypes and joint line obliquity in a great majority of varus and straight knees and normalises valgus and severe varus deformities.

PURPOSE: The present study focuses on testing the capability of a restricted tibia-first, gap-balanced patient-specific alignment technique (PSA) to restore bony morphology and phenotypes. METHODS: Three-hundred and sixty-seven patients were treated with navigated total knee arthroplasty and tibia-first gap-balanced PSA technique. Boundaries for medial proximal tibial angle were 86°-92°, mechanical lateral distal femoral angle 86°-92°, and hip-knee-ankle angle 175°-183°. Knees were classified by coronal plane alignment of the knee (CPAK), with subsequent analyses comparing pre- and postoperative distributions. Phenotype classification within CPAK groups assessed pre- and postoperative distributions. RESULTS: Preoperatively, the largest CPAK group was type II (30.8%), followed by type I (20.5%) and type V (17.8%). Postoperatively, type II remained the largest group (39%), followed by type V (30%). All groups with varus/valgus deformities (I, III, IV and VI) became smaller. While in straight legs (II, IV), the CPAK was restored in more than 70%-75%, in varus groups (I, IV) in 40%-50% and in valgus (III and VI) in 5%-18%. The joint line obliquity remained the same in the majority of knees (straight >75%; varus 63%-80%; valgus VI 95%), with the exception of CPAK III (40%). The phenotype analysis showed for straight legs a phenotype restoration of 85%, for varus 94% and for valgus 37%. Joint line convergence angle was reduced significantly in all groups from 1.8°-4.3° preoperatively to 0.6°-1.2° postoperatively. CONCLUSION: PSA restores bony phenotypes and joint line obliquity in the majority of straight and varus knees, while most of the valgus and extreme varus knees are normalised. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Tibia-first, gap-balanced patient-specific alignment technique achieves well-balanced gaps in 90% of cases by rebuilding bony anatomy within boundaries.

PURPOSE: Patient-specific alignment (PSA) technique tries to achieve balanced gaps and simultaneously rebuild the individual bony phenotype. The hypothesis was: PSA technique achieves balanced knees in a high percentage with more anatomical resections than adjusted mechanical alignment (AMA). METHODS: Three hundred sixty-seven patients underwent navigated total knee arthroplasty (TKA) with a tibia-first gap-balanced PSA technique. Resection boundaries for medial proximal tibia angle (MPTA) of 86-92°, mechanical lateral distal femoral angle (mLDFA) of 86-92°, and hip-knee-ankle angle (HKA) of 175-185° were defined. Preoperative and intraoperative parameters of HKA, MPTA, mLDFA, and gap widths were recorded. Depending on the coronal deformity, the patients were divided into three groups: varus HKA < 178°; straight 178-182° and valgus HKA > 182°. The stability was analysed by assessing the difference between medial and lateral extension and flexion gaps as well as between flexion and extension gaps. All PSA measurements were compared with data from a previously published AMA series. RESULTS: PSA achieved balanced gaps in extension, flexion and between flexion/extension in over 90% of cases, being similar to AMA. In PSA, MPTA and mLDFA were restored within 1°, except in extreme varus (MPTA difference 2°) and valgus knees (mLDFA difference 3°). This was caused by the defined boundaries of the alignment technique. This individualised reconstruction led to significantly more anatomical resections of all tibia and femur resections. CONCLUSION: A tibia-first, gap-balanced PSA technique achieves balanced joints in more than 90% of cases. By maintaining preoperative MPTA and mLDFA to a high extent, far more anatomical resections, compared to AMA were performed. Future studies need to be conducted to investigate whether those promising intraoperative results correlate with postoperative patient outcomes and whether patients outside the 5° corridor have higher failure rates. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Quantitative differences in activities of back and pelvic limb muscles during walking and trotting between chronically lame and nonlame horses.

OBJECTIVE: To assess differences in activities of back and pelvic limb muscles by use of surface electromyography (SEMG) in chronically lame and nonlame horses during walking and trotting. ANIMALS: 12 nonlame horses and 12 horses with unilateral chronic mild to moderate pelvic limb lameness. PROCEDURES: On each horse, bipolar electrodes were attached to the skin over the midpoints of the right and left longissimus thoracis (Lot), semitendinosus (Set), biceps femoris (Bif), gluteus medius (Glm), and extensor digitorum longus (Edl) muscles. For each muscle, synchronous kinematic and SEMG recordings were made during walking and trotting on a treadmill; mean, maximum, and minimum muscle activities and maximum-to-mean and minimum-to-mean activity ratios were determined. For each lame or nonlame horse, data from both pelvic limbs were averaged; in lame horses, data from the nonlame and lame pelvic limbs were also examined separately (NL-L and L-L values, respectively). Comparisons were made among the 4 data sets and between gaits. RESULTS: During walking, the NL-L maximum-to-mean ratios for Bif and Glm muscles were significantly greater and in lame horses, L-L and NL-L minimum-to-mean ratios for Set, Bif, Glm, and Lot muscles were significantly less than those for nonlame horses. During trotting, minimum-to-mean ratios for Set, Glm, and Lot muscles in lame horses were significantly lower than those for nonlame horses. Activity of the Edl muscle was not affected by lameness. CONCLUSIONS AND CLINICAL RELEVANCE: In lame horses, variation in muscle use was detectable via SEMG. In chronically lame horses, back and pelvic limb muscle activities were affected differently during walking and trotting.