Anterior referencing of tibial slope in total knee arthroplasty considerably influences knee kinematics: a musculoskeletal simulation study

Knee Surg Sports Traumatol Arthrosc. 2018 May;26(5):1540-1548. doi: 10.1007/s00167-017-4561-3. Epub 2017 May 12.


Purpose: In total knee arthroplasty (TKA), the posterior tibial slope is not always reconstructed correctly, and the knee ligaments may become too tight in flexion. To release a tight flexion gap, surgeons can increase the posterior tibial slope using two surgical resection techniques: the anterior tibial cortex (ACR) or the centre of tibial plateau (CPR) referencing. It is not known how this choice affects the knee laxity and function during activities of daily living. The aim of this study was to investigate the effect of tibial slope on knee laxity, kinematics and forces during a squatting activity using computer simulation techniques. We hypothesised that the effects depend on the referencing technique utilised.

Methods: A validated musculoskeletal model of TKA was used. Knee laxity tests were simulated in flexion and extension. Then, a squat motion was simulated to calculate: movement of the tibiofemoral joint (TFJ) contact points and patello-femoral joint (PFJ) contact force. All analyses were repeated with more anterior (-3°), neutral (0°), and more posterior tibial slope (+3°, +6°, +9°), and with two referencing techniques (ACR, CPR).

Results: Knee laxities increased dramatically with more posterior slope with the ACR technique (up to 400%), both in flexion and in extension. The CPR technique, instead, had much smaller effects (up to 42% variations). During squatting, more slope with the ACR technique resulted in larger movements of the TFJ contact point. The PFJ contact force decreased considerably with more slope with the CPR technique (12% body weight reduction every 3° more posterior slope), thanks to the preservation of the patellar height and quadriceps-femur load sharing.

Conclusion: ACR technique alters considerably the knee laxity, both in flexion and extensions, and surgeons should be cautious about its use. More slope with CPR technique induces more favourable TFJ kinematics and loading of the knee extensor apparatus and does not substantially alter knee laxity. Preferably, the tibial slope resection should be pre-planned thoroughly and performed using CPR technique as accurately as possible. Surgeons can directly translate the results of this study into the clinical practice.

Keywords: Arthroplasty; Biomechanics; CR; Computer; Dependent; Force; Kinematics; Knee; Model; Musculoskeletal; Posterior; Simulation; Slope; TKA; Tibial.

MeSH terms

  • Activities of Daily Living
  • Aged
  • Arthroplasty, Replacement, Knee*
  • Biomechanical Phenomena
  • Computer Simulation*
  • Femur / surgery
  • Humans
  • Knee Joint / physiology*
  • Knee Joint / surgery
  • Ligaments, Articular / surgery
  • Patella / surgery
  • Patellofemoral Joint / surgery
  • Quadriceps Muscle / physiology
  • Range of Motion, Articular
  • Tibia / anatomy & histology*
  • Tibia / surgery