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1.  A morphometric study of normal and varus knees 
The aim of the study was to investigate varus and normal knee morphologies to identify differences that may affect knee replacement alignment or design for varus knees.
Computed tomography scans of varus and normal knees were analyzed, and geometric shapes, points and axes were fit to the femur and tibia independently. These points were then projected in the three anatomical planes to measure the variations between the two groups.
In the femur, varus knees had less femoral anteversion (p < 0.0001) and a larger medial extension facet (p < 0.05) compared with normal knees. In the tibia, the tubercle was found to be externally rotated in varus knees (12°), with a significant increase in the coronal slope (p = 0.001) and the extension facet angle (p = 0.002).
The study highlighted the differences and similarities found between the two groups, which raises awareness on changes required during surgical intervention and component placement or design for a varus knee. This is particularly relevant for the design of patient-specific instrumentation and implants.
Levels of evidence
Diagnostic study, Level III.
PMCID: PMC4237928  PMID: 25261224
Morphometry; Varus knee; Morphology; Rotational alignment; Axes
2.  A CT scan protocol for the detection of radiographic loosening of the glenoid component after total shoulder arthroplasty 
Acta Orthopaedica  2014;85(1):91-96.
Background and purpose
It is difficult to evaluate glenoid component periprosthetic radiolucencies in total shoulder arthroplasties (TSAs) using plain radiographs. This study was performed to evaluate whether computed tomography (CT) using a specific patient position in the CT scanner provides a better method for assessing radiolucencies in TSA.
Following TSA, 11 patients were CT scanned in a lateral decubitus position with maximum forward flexion, which aligns the glenoid orientation with the axis of the CT scanner. Follow-up CT scanning is part of our routine patient care. Glenoid component periprosthetic lucency was assessed according to the Molé score and it was compared to routine plain radiographs by 5 observers.
The protocol almost completely eliminated metal artifacts in the CT images and allowed accurate assessment of periprosthetic lucency of the glenoid fixation. Positioning of the patient within the CT scanner as described was possible for all 11 patients. A radiolucent line was identified in 54 of the 55 observed CT scans and osteolysis was identified in 25 observations. The average radiolucent line Molé score was 3.4 (SD 2.7) points with plain radiographs and 9.5 (SD 0.8) points with CT scans
(p = 0.001). The mean intra-observer variance was lower in the CT scan group than in the plain radiograph group (p = 0.001).
The CT scan protocol we used is of clinical value in routine assessment of glenoid periprosthetic lucency after TSA. The technique improves the ability to detect and monitor radiolucent lines and, therefore, possibly implant loosening also.
PMCID: PMC3940998  PMID: 24286563
3.  Accuracy of Glenoid Component Placement in Total Shoulder Arthroplasty and Its Effect on Clinical and Radiological Outcome in a Retrospective, Longitudinal, Monocentric Open Study 
PLoS ONE  2013;8(10):e75791.
The success of Total Shoulder Arthroplasty (TSA) is believed to depend on the restoration of the natural anatomy of the joint and a key development has been the introduction of modular humeral components to more accurately restore the patient’s anatomy. However, there are no peer-reviewed studies that have reported the degree of glenoid component mal-position achieved in clinical practice and the clinical outcome of such mal-position. The main purpose of this study was to assess the accuracy of glenoid implant positioning during TSA and to relate it to the radiological (occurrence of radiolucent lines and osteolysis on CT) and clinical outcomes.
68 TSAs were assessed with a mean follow-up of 38+/−27 months. The clinical evaluation consisted of measuring the mobility as well as of the Constant Score. The radiological evaluation was performed on CT-scans in which metal artefacts had been eliminated. From the CT-scans radiolucent lines and osteolysis were assessed. The positions of the glenoid and humeral components were also measured from the CT scans.
Four position glenoid component parameters were calculated The posterior version (6°±12°; mean ± SD), the superior tilt (12°±17°), the rotation of the implant relative to the scapular plane (3°±14°) and the off-set distance of the centre of the glenoid implant from the scapular plane (6±4 mm). An inferiorly inclined implant was found to be associated with higher levels of radiolucent lines while retroversion and non-neutral rotation were associated with a reduced range of motion.
this study demonstrates that glenoid implants of anatomic TSA are poorly positioned and that this malposition has a direct effect on the clinical and radiological outcome. Thus, further developments in glenoid implantation techniques are required to enable the surgeon to achieve a desired implant position and outcome.
PMCID: PMC3793002  PMID: 24116075
4.  Unicompartmental Knee Arthroplasty Enables Near Normal Gait at Higher Speeds, Unlike Total Knee Arthroplasty 
The Journal of Arthroplasty  2013;28(9):176-178.
Top walking speed (TWS) was used to compare UKA with TKA. Two groups of 23 patients, well matched for age, gender, height and weight and radiological severity were recruited based on high functional scores, more than twelve months post UKA or TKA. These were compared with 14 preop patients and 14 normal controls. Their gait was measured at increasing speeds on a treadmill instrumented with force plates. Both arthroplasty groups were significantly faster than the preop OA group. TKA patients walked substantially faster than any previously reported series of knee arthroplasties. UKA patients walked 10% faster than TKA, although not as fast as the normal controls. Stride length was 5% greater and stance time 7% shorter following UKA — both much closer to normal than TKA. Unlike TKA, UKA enables a near normal gait one year after surgery.
PMCID: PMC3809509  PMID: 24099573
gait; walking speed; stride length; unicompartmental knee arthroplasty; total knee arthroplasty
5.  A quantitative technique to create a femoral tunnel at the averaged center of the anteromedial bundle attachment in anatomic double-bundle anterior cruciate ligament reconstruction 
In the anatomic double-bundle ACL reconstruction, 2 femoral tunnel positions are particularly critical to obtain better clinical results. Recently, a few studies have reported quantitative identification methods for posterolateral (PL) bundle reconstruction. Concerning anteromedial (AM) bundle reconstruction, however, no quantitative clinically available methods to insert a guide wire at the center of the direct attachment of the AM mid-substance fibers have been reported to date.
First, we determined the center of the femoral attachment of the AM mid-substance fibers using 38 fresh frozen cadaveric knees. Based on this anatomical sub-study, we developed a quantitative clinical technique to insert a guide wire at the averaged center for anatomic double-bundle ACL reconstruction. In the second clinical sub-study with 63 patients who underwent anatomic ACL reconstruction with this quantitative technique, we determined the center of an actually created AM tunnel. Then, we compared the results of the second sub-study with those of the first sub-study to validate the accuracy of the quantitative technique. In both the sub-studies, we determined the center of the anatomical attachment and the tunnel outlet using the “3-dimensional clock” system. The tunnel outlet was evaluated using the “transparent” 3-dimensional computed tomography.
The averaged center of the direct attachment of the AM bundle midsubstance fibers was located on the cylindrical surface of the femoral intercondylar notch at “10:37” (or “1:23”) o’clock orientation in the distal view and at 5.0-mm from the proximal outlet of the intercondylar notch (POIN) in the lateral view. The AM tunnel actually created in ACL reconstruction was located at “10:41” (or “1:19”) o’clock orientation in the average and at 5.0-mm from the POIN. There was no significant difference between the 2 center locations.
The quantitative technique enabled us to easily create the femoral AM tunnel at the averaged center of the direct attachment of the AM bundle midsubstance fibers with high accuracy. This study reported information on the geometric location of the femoral attachment of the AM bundle and a clinically useful technique for its anatomical reconstruction.
PMCID: PMC3689614  PMID: 23767886
Anterior cruciate ligament; Anatomic reconstruction; Anteromedial bundle; Femoral tunnel; Footprint attachment location
6.  Total shoulder arthroplasty does not correct the orientation of the eroded glenoid 
Acta Orthopaedica  2012;83(5):529-535.
Background and purpose
Alignment of the glenoid component with the scapula during total shoulder arthroplasty (TSA) is challenging due to glenoid erosion and lack of both bone stock and guiding landmarks. We determined the extent to which the implant position is governed by the preoperative erosion of the glenoid. Also, we investigated whether excessive erosion of the glenoid is associated with perforation of the glenoid vault.
We used preoperative and postoperative CT scans of 29 TSAs to assess version, inclination, rotation, and offset of the glenoid relative to the scapula plane. The position of the implant keel within the glenoid vault was classified into three types: centrally positioned, component touching vault cortex, and perforation of the cortex.
Preoperative glenoid erosion was statistically significantly linked to the postoperative placement of the implant regarding all position parameters. Retroversion of the eroded glenoid was on average 10° (SD10) and retroversion of the implant after surgery was 7° (SD11). The implant keel was centered within the vault in 7 of 29 patients and the glenoid vault was perforated in 5 patients. Anterior cortex perforation was most frequent and was associated with severe preoperative posterior erosion, causing implant retroversion.
The position of the glenoid component reflected the preoperative erosion and “correction” was not a characteristic of the reconstructive surgery. Severe erosion appears to be linked to vault perforation. If malalignment and perforation are associated with loosening, our results suggest reorientation of the implant relative to the eroded surface.
PMCID: PMC3488182  PMID: 23083436
7.  Validation of an ear-worn sensor for gait monitoring using a force-plate instrumented treadmill 
Gait & Posture  2012;35(4):674-676.
A force-plate instrumented treadmill (Hp Cosmos Gaitway) was used to validate the use of a miniaturised lightweight ear-worn sensor (7.4 g) for gait monitoring. Thirty-four healthy subjects were asked to progress up to their maximum walking speed on the treadmill (starting at 5 km/h, with 0.5 km increments). The sensor houses a 3D accelerometer which measures medio-lateral (ML), vertical (VT) and anterior–posterior (AP) acceleration. Maximum signal ranges and zero crossings were derived from accelerometer signals per axis, having corrected for head motion and signal noise. The maximal force, measured by the instrumented treadmill correlated best with a combination of VT and AP acceleration (R-squared = 0.36, p = 0), and combined VT, ML, and AP acceleration (R-squared = 0.36, p = 0). Weight-acceptance peak force and impulse values also correlated well with VT and AP acceleration (Weight acceptance: R-squared = 0.35, p = 0, Impulse: 0.26, p = 0), and combined VT, ML, and AP acceleration (Weight acceptance: R-squared = 0.35, p = 0, Impulse: 0.26, p = 0). Zero crossing features on the ML axis provided an accurate prediction of the gait-cycle, with a mean difference of 0.03 s (−0.01, 0.05 confidence intervals).
PMCID: PMC3329626  PMID: 22169386
Wearable sensors; Body sensor networks; Accelerometer; Gait cycle; Instrumented treadmill
8.  The Geometry of the Trochlear Groove 
In the natural and prosthetic knees the position, shape, and orientation of the trochlea groove are three of the key determinants of function and dysfunction, yet the rules governing these three features remain elusive.
The aim was to define the three-dimensional geometry of the femoral trochlea and its relation to the tibiofemoral joint in terms of angles and distances.
Forty CT scans of femurs of healthy patients were analyzed using custom-designed imaging software. After aligning the femur using various axes, the locations and orientations of the groove and the trochlear axis were examined in relation to the conventional axes of the femur.
The trochlear groove was circular and positioned laterally in relation to the mechanical, anatomic, and transcondylar axes of the femur; it was not aligned with any of these axes. We have defined the trochlear axis as a line joining the centers of two spheres fitted to the trochlear surfaces lateral and medial to the trochlear groove. When viewed after aligning the femur to this new axis, the trochlear groove appeared more linear than when other methods of orientation were used.
Our study shows the importance of reliable femoral orientation when reporting the shape of the trochlear groove.
PMCID: PMC2816780  PMID: 19915941
9.  Surgical anatomy of the foot and ankle 
PMCID: PMC2855023  PMID: 20306016
10.  The structural properties of the lateral retinaculum and capsular complex of the knee 
Journal of Biomechanics  2009;42(14):2323-2329.
Although lateral retinacular releases are not uncommon, there is very little scientific knowledge about the properties of these tissues, on which to base a rationale for the surgery. We hypothesised that we could identify specific tissue bands and measure their structural properties. Eight fresh-frozen knees were dissected, and the lateral soft tissues prepared into three distinct structures: a broad tissue band linking the iliotibial band (ITB) to the patella, and two capsular ligaments: patellofemoral and patellomeniscal. These were individually tensile tested to failure by gripping the patella in a vice jaw and the soft tissues in a freezing clamp. Results: the ITB–patellar band was strongest, at a mean of 582 N, and stiffest, at 97 N/mm. The patellofemoral ligament failed at 172 N with 16 N/mm stiffness; the patellomeniscal ligament failed at 85 N, with 13 N/mm stiffness. These structural properties suggest that most of the load in-vivo is transmitted to the patella by the transverse fibres that originate from the ITB.
PMCID: PMC2764350  PMID: 19647256
Patella; Patellofemoral joint; Strength; Structural properties; Lateral retinaculum; Iliotibial band
11.  Changes in Knee Kinematics Reflect the Articular Geometry after Arthroplasty 
We hypothesized changes in rotations and translations after TKA with a fixed-bearing anterior cruciate ligament (ACL)-sacrificing but posterior cruciate ligament (PCL)-retaining design with equal-sized, circular femoral condyles would reflect the changes of articular geometry. Using 8 cadaveric knees, we compared the kinematics of normal knees and TKA in a standardized navigated position with defined loads. The quadriceps was tensed and moments and drawer forces applied during knee flexion-extension while recording the kinematics with the navigation system. TKA caused loss of the screw-home; the flexed tibia remained at the externally rotated position of normal full knee extension with considerably increased external rotation from 63° to 11° extension. The range of internal-external rotation was shifted externally from 30° to 20° extension. There was a small tibial posterior translation from 40° to 90° flexion. The varus-valgus alignment and laxity did not change after TKA. Thus, navigated TKA provided good coronal plane alignment but still lost some aspects of physiologic motion. The loss of tibial screw-home was related to the symmetric femoral condyles, but the posterior translation in flexion was opposite the expected change after TKA with the PCL intact and the ACL excised. Thus, the data confirmed our hypothesis for rotations but not for translations. It is not known whether the standard navigated position provides the best match to physiologic kinematics.
PMCID: PMC2584306  PMID: 18704612
12.  The Width:thickness Ratio of the Patella 
Establishing the appropriate size of the patellar implant-bone composite is one of the important steps ensuring functional success in arthroplasty. Conventionally, the patella is measured intraoperatively and its thickness is used to guide the depth of resection. However, in a diseased joint, this may not reflect the native patellar thickness. We studied the relationship between the patellar thickness and various patellar dimensions on three-dimensional reconstructed computed tomographic scans from 37 normal adult knees. Patellar width correlated with thickness. The average patellar width:thickness ratio was 2.0 (standard deviation, 0.106; 95% confidence interval, 1.96–2.03). The cartilage thickness was on average 2.5 mm (standard deviation, 1.0). The width:thickness ratio was similar in 79 digital radiographs taken before TKA of knees without patellofemoral disease (mean, 2.1; standard deviation, 0.28). When compared with the two other methods for calculating patellar resection described in the literature, the width:thickness ratio was more reliable. The width:thickness ratio appears anatomically constant and may be a useful guide for estimating premorbid patellar thickness.
PMCID: PMC2311467  PMID: 18330664

Results 1-12 (12)