Biomechanical research on effects of pseudo-patella baja on stress of patellofemoral joint after total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WEI Wenxing , NIE Yong , WU Yuangang ,  SHEN Bin

Department of Orthopaedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

SHEN Bin, Email: shenbin71@hotmail.com

Keywords：

Knee; total knee arthroplasty; pseudo-patella baja; patellofemoral joint; finite element analysis

DOI：

10.7507/1002-1892.202101166

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Objective To investigate biomechanical effects of pseudo-patella baja on stress of patellofemoral joint after total knee arthroplasty (TKA) by using finite element analysis (FEA).Methods A series of CT and MRI of the left knee joint of two healthy volunteers and three-dimensional (3D) scanned data of TKA prosthesis were taken, and the 3D models of knee before and after TKA were established. The finite element model of pseudo-patella baja, normal patella, and alta patella after TKA were constructed by Insall-Salvafi (IS) ratio and Blackburne-Peel (BP) ratio. The load was applied along the direction of quadriceps femoris. After testing the validity of the finite element model, the high contact stress of patellofemoral joint was measured on the von Mise stress nephogram of pseudo-patella baja, normal patella, and alta patella after TKA when the knee flexion was 30°, 60°, and 90°. The average contact area was calculated according to two volunteers’ data.Results On the finite element model of the normal patella after TKA with knee flexion 30°, 475 N pressure was applied along the direction of quadriceps femoris. The contact stress of patellofemoral joint was (1.29±0.41) MPa, which was similar to the results reported previously. The finite element model was valid. The von Mise stress nephogram showed that the stress mainly focused on the medial patellofemoral articular surface during knee flexion, and the contact point gradually moved up with the knee flexion deepened. The stress on the medial and lateral patellofemoral articular surface increased with the knee flexion deepened but decreased with the increase of patellar height. The effects of patellar height and knee flexion on the high contact stress of patellofemoral joint were similar among the finite element models after TKA based on the data of two volunteers. The high contact stress of patellofemoral joint increased with the knee flexion deepened in the same patellar height models (P<0.05), but decreased with the increase of patellar height in the same knee flexion models (P<0.05). The high contact stress of patellofemoral joint of pseudo-patella baja model was significantly higher than normal and alta patella models (P<0.05). The average contact area of patellofemoral joint of pseudo-patella baja was bigger than normal and alta patella models with the knee flexion deepened.Conclusion The pseudo-patella baja after TKA has an important effect on the biomechanics of patellofemoral joint. Reserving the joint line and avoiding the occurrence of pseudo-patella baja can decrease the risk of anterior knee pain, patellar arthritis, and other complications caused by the increasing of contact stress of patellofemoral joint.

Citation： WEI Wenxing, NIE Yong, WU Yuangang, SHEN Bin. Biomechanical research on effects of pseudo-patella baja on stress of patellofemoral joint after total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(7): 841-846. doi: 10.7507/1002-1892.202101166 Copy

1.	Sartawi M, Zurakowski D, Rosenberg A. Implant survivorship and complication rates after total knee arthroplasty with a third-generation cemented system: 15-year follow-up. Am J Orthop (Belle Mead NJ), 2018, 47(3). doi: 10.12788/ajo.2018.0018.
2.	McMahon SE, Doran E, O’Brien S, et al. Seventeen to twenty years of follow-up of the low contact stress rotating-platform total knee arthroplasty with a cementless tibia in all cases. J Arthroplasty, 2019, 34(3): 508-512.
3.	Kazemi SM, Daftari Besheli L, Eajazi A, et al. Pseudo-patella baja after total knee arthroplasty. Med Sci Monit, 2011, 17(5): CR292-296.
4.	Behrend H, Graulich T, Gerlach R, et al. Blackburne-Peel ratio predicts patients’ outcomes after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1562-1569.
5.	Gaillard R, Bankhead C, Budhiparama N, et al. Influence of patella height on total knee arthroplasty: outcomes and survival. J Arthroplasty, 2019, 34(3): 469-477.
6.	Seo JG, Moon YW, Kim SM, et al. Prevention of pseudo-patella baja during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2015, 23(12): 3601-3606.
7.	Babazadeh S, Dowsey MM, Swan JD, et al. Joint line position correlates with function after primary total knee replacement: a randomised controlled trial comparing conventional and computer-assisted surgery. J Bone Joint Surg (Br), 2011, 93(9): 1223-1231.
8.	Fox AJ, Wanivenhaus F, Rodeo SA. The basic science of the patella: structure, composition, and function. J Knee Surg, 2012, 25(2): 127-141.
9.	Takahashi A, Sano H, Ohnuma M, et al. Patellar morphology and femoral component geometry influence patellofemoral contact stress in total knee arthroplasty without patellar resurfacing. Knee Surg Sports Traumatol Arthrosc, 2012, 20(9): 1787-1795.
10.	Fitzpatrick CK, Baldwin MA, Laz PJ, et al. Development of a statistical shape model of the patellofemoral joint for investigating relationships between shape and function. J Biomech, 2011, 44(13): 2446-2452.
11.	Insall J, Salvati E. Patella position in the normal knee joint. Radiology, 1971, 101(1): 101-104.
12.	Blackburne JS, Peel TE. A new method of measuring patellar height. J Bone Joint Surg (Br), 1977, 59(2): 241-242.
13.	Xu B, Xu WX, Lu D, et al. Application of different patella height indices in patients undergoing total knee arthroplasty. J Orthop Surg Res, 2017, 12(1): 191. doi: 10.1186/s13018-017-0694-9.
14.	Tuncer M, Cobb JP, Hansen UN, et al. Validation of multiple subject-specific finite element models of unicompartmental knee replacement. Med Eng Phys, 2013, 35(10): 1457-1464.
15.	Nie Y, Pei F, Shen B, et al. Importance of maintaining the basic stress pathway above the acetabular dome during acetabular reconstruction. Comput Methods Biomech Biomed Engin, 2016, 19(9): 977-984.
16.	Morgan EF, Bayraktar HH, Keaveny TM. Trabecular bone modulus-density relationships depend on anatomic site. J Biomech, 2003, 36(7): 897-904.
17.	Weiss JA, Gardiner JC, Bonifasi-Lista C. Ligament material behavior is nonlinear, viscoelastic and rate-independent under shear loading. J Biomech, 2002, 35(7): 943-950.
18.	Gardiner JC, Weiss JA. Subject-specific finite element analysis of the human medial collateral ligament during valgus knee loading. J Orthop Res, 2003, 21(6): 1098-1106.
19.	Butler DL, Sheh MY, Stouffer DC, et al. Surface strain variation in human patellar tendon and knee cruciate ligaments. J Biomech Eng, 1990, 112(1): 38-45.
20.	Fitzpatrick CK, Baldwin MA, Rullkoetter PJ. Computationally efficient finite element evaluation of natural patellofemoral mechanics. J Biomech Eng, 2010, 132(12): 121013. doi: 10.1115/1.4002854.
21.	Luyckx T, Didden K, Vandenneucker H, et al. Is there a biomechanical explanation for anterior knee pain in patients with patella alta?: influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg (Br), 2009, 91(3): 344-350.
22.	Innocenti B, Pianigiani S, Labey L, et al. Contact forces in several TKA designs during squatting: A numerical sensitivity analysis. J Biomech, 2011, 44(8): 1573-1581.
23.	König C, Sharenkov A, Matziolis G, et al. Joint line elevation in revision TKA leads to increased patellofemoral contact forces. J Orthop Res, 2010, 28(1): 1-5.
24.	Singerman R, Davy DT, Goldberg VM. Effects of patella alta and patella infera on patellofemoral contact forces. J Biomech, 1994, 27(8): 1059-1065.
25.	Tanikawa H, Tada M, Harato K, et al. Influence of total knee arthroplasty on patellar kinematics and patellofemoral pressure. J Arthroplasty, 2017, 32(1): 280-285.

1. Sartawi M, Zurakowski D, Rosenberg A. Implant survivorship and complication rates after total knee arthroplasty with a third-generation cemented system: 15-year follow-up. Am J Orthop (Belle Mead NJ), 2018, 47(3). doi: 10.12788/ajo.2018.0018.
2. McMahon SE, Doran E, O’Brien S, et al. Seventeen to twenty years of follow-up of the low contact stress rotating-platform total knee arthroplasty with a cementless tibia in all cases. J Arthroplasty, 2019, 34(3): 508-512.
3. Kazemi SM, Daftari Besheli L, Eajazi A, et al. Pseudo-patella baja after total knee arthroplasty. Med Sci Monit, 2011, 17(5): CR292-296.
4. Behrend H, Graulich T, Gerlach R, et al. Blackburne-Peel ratio predicts patients’ outcomes after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1562-1569.
5. Gaillard R, Bankhead C, Budhiparama N, et al. Influence of patella height on total knee arthroplasty: outcomes and survival. J Arthroplasty, 2019, 34(3): 469-477.
6. Seo JG, Moon YW, Kim SM, et al. Prevention of pseudo-patella baja during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2015, 23(12): 3601-3606.
7. Babazadeh S, Dowsey MM, Swan JD, et al. Joint line position correlates with function after primary total knee replacement: a randomised controlled trial comparing conventional and computer-assisted surgery. J Bone Joint Surg (Br), 2011, 93(9): 1223-1231.
8. Fox AJ, Wanivenhaus F, Rodeo SA. The basic science of the patella: structure, composition, and function. J Knee Surg, 2012, 25(2): 127-141.
9. Takahashi A, Sano H, Ohnuma M, et al. Patellar morphology and femoral component geometry influence patellofemoral contact stress in total knee arthroplasty without patellar resurfacing. Knee Surg Sports Traumatol Arthrosc, 2012, 20(9): 1787-1795.
10. Fitzpatrick CK, Baldwin MA, Laz PJ, et al. Development of a statistical shape model of the patellofemoral joint for investigating relationships between shape and function. J Biomech, 2011, 44(13): 2446-2452.
11. Insall J, Salvati E. Patella position in the normal knee joint. Radiology, 1971, 101(1): 101-104.
12. Blackburne JS, Peel TE. A new method of measuring patellar height. J Bone Joint Surg (Br), 1977, 59(2): 241-242.
13. Xu B, Xu WX, Lu D, et al. Application of different patella height indices in patients undergoing total knee arthroplasty. J Orthop Surg Res, 2017, 12(1): 191. doi: 10.1186/s13018-017-0694-9.
14. Tuncer M, Cobb JP, Hansen UN, et al. Validation of multiple subject-specific finite element models of unicompartmental knee replacement. Med Eng Phys, 2013, 35(10): 1457-1464.
15. Nie Y, Pei F, Shen B, et al. Importance of maintaining the basic stress pathway above the acetabular dome during acetabular reconstruction. Comput Methods Biomech Biomed Engin, 2016, 19(9): 977-984.
16. Morgan EF, Bayraktar HH, Keaveny TM. Trabecular bone modulus-density relationships depend on anatomic site. J Biomech, 2003, 36(7): 897-904.
17. Weiss JA, Gardiner JC, Bonifasi-Lista C. Ligament material behavior is nonlinear, viscoelastic and rate-independent under shear loading. J Biomech, 2002, 35(7): 943-950.
18. Gardiner JC, Weiss JA. Subject-specific finite element analysis of the human medial collateral ligament during valgus knee loading. J Orthop Res, 2003, 21(6): 1098-1106.
19. Butler DL, Sheh MY, Stouffer DC, et al. Surface strain variation in human patellar tendon and knee cruciate ligaments. J Biomech Eng, 1990, 112(1): 38-45.
20. Fitzpatrick CK, Baldwin MA, Rullkoetter PJ. Computationally efficient finite element evaluation of natural patellofemoral mechanics. J Biomech Eng, 2010, 132(12): 121013. doi: 10.1115/1.4002854.
21. Luyckx T, Didden K, Vandenneucker H, et al. Is there a biomechanical explanation for anterior knee pain in patients with patella alta?: influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg (Br), 2009, 91(3): 344-350.
22. Innocenti B, Pianigiani S, Labey L, et al. Contact forces in several TKA designs during squatting: A numerical sensitivity analysis. J Biomech, 2011, 44(8): 1573-1581.
23. König C, Sharenkov A, Matziolis G, et al. Joint line elevation in revision TKA leads to increased patellofemoral contact forces. J Orthop Res, 2010, 28(1): 1-5.
24. Singerman R, Davy DT, Goldberg VM. Effects of patella alta and patella infera on patellofemoral contact forces. J Biomech, 1994, 27(8): 1059-1065.
25. Tanikawa H, Tada M, Harato K, et al. Influence of total knee arthroplasty on patellar kinematics and patellofemoral pressure. J Arthroplasty, 2017, 32(1): 280-285.

Chinese Journal of Reparative and Reconstructive Surgery

Biomechanical research on effects of pseudo-patella baja on stress of patellofemoral joint after total knee arthroplasty

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