The Journal of Arthroplasty Vol. 27 No.

6 2012

Changes in Posterior Condylar Offset After Total Knee Arthroplasty Cannot be Determined by Radiographic Measurements Alone
Henry D. Clarke, MD

Abstract: Restoration of femoral posterior condylar offset (PCO) may contribute to maximum flexion after total knee arthroplasty. Accurate radiographic measurement of postoperative PCO is possible, as the prosthesis margins can be easily identified; however, preoperative measurement of PCO may be inaccurate, as the remaining cartilage thickness of the posterior condyles is not included. This error may contribute to the controversy surrounding the importance of PCO. In this institutional review boardapproved study, the cartilage thickness of posterior condylar specimens resected during total knee arthroplasty was measured. Mean cartilage thicknesses of the posterior condyles were 1.7 mm (range, 0-4 mm) medially and 2.0 mm (range, 0-5 mm) laterally. As the cartilage thickness is variable, future studies of PCO must adjust the preoperative radiographic measurements by the cartilage thickness measured intraoperatively. Keywords: total knee arthroplasty, radiographic measurements, posterior condylar offset. 2012 Elsevier Inc. All rights reserved.

Extensive research has been conducted to determine the variables that influence the range of motion that is obtained after total knee arthroplasty (TKA) [1-9]. Rather than a single variable, it appears that numerous factors may make important contributions: prosthesis design appears to play a role, as do patient-related factors, such as the preoperative range of motion of the knee [1-8]. Furthermore, certain aspects of the surgical technique have also been implicated including the amount of posterior tibial slope and whether posterior femoral osteophytes are adequately removed [9-11]. Restoration of femoral posterior condylar offset (PCO) has also been identified as a potentially important variable, yet the magnitude of the effect has been debated, with some authors noting no effect, and others reporting as little as a 1-mm reduction in PCO reducing maximum flexion by as much as 5 [10-18]. In these prior studies, the same technique has been used to measure the PCO. As first described by Bellemans et al [12], the PCO is evaluated on a true lateral radiograph of the distal femur by measuring the maximum thickness of the posterior

From the Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona. Submitted November 13, 2011; accepted December 24, 2011. The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.12.026. Reprint requests: Henry D. Clarke, MD, Department of Orthopedics, Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ 85054. 2012 Elsevier Inc. All rights reserved. 0883-5403/2706-0054$36.00/0 doi:10.1016/j.arth.2011.12.026

condyle, projected posteriorly to the tangent of the posterior cortex of the femoral shaft (Fig. 1A and B). Preoperative and postoperative measurements are then compared after adjusting the raw thickness by a magnification correction that is based upon a reference measurement of the diameter of the femoral shaft 10 cm proximal to the articular surface [12]. On the postoperative view, the inferior most aspects of the posterior condyles of the metal femoral component can be accurately identified (Fig. 1B). However, on the preoperative views, the inferior aspects of the posterior condyles are assumed to be represented by the bony margin (Fig. 1A). None of the prior studies have accounted for the thickness of the remaining cartilage on the posterior condyles (Figs. 2 and 3). Therefore, if this remaining cartilage is significant and variable in thickness, it would render calculations of changes in PCO inaccurate. This may account for some of the controversy regarding the effect of changes in PCO on range of motion after TKA. The purposes of this study were (1) to determine the thickness and variability of the remaining cartilage on the posterior condyles in patients under going TKA and (2) to identify whether the preoperative varus or valgus alignment influenced the remaining cartilage thickness.

Materials and Methods

Institutional review board approval was obtained from our institution before proceeding with this study to retrospectively review data that were obtained prospectively during TKA. Data from 158 consecutive knees

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who underwent staged bilateral TKA during this period were used. These exclusions were implemented because it was considered likely that the anatomical findings in 2 knees from the same individual would be similar. As a result of these 13 exclusions, data from 145 knees from 145 patients were reviewed. Data from 1 knee were missing for the medial condyle measurement and from 1 different knee for the lateral condyle; therefore, data from 144 knees were analyzed for each condyle. In all cases, after the distal femoral cut had been performed, a posterior referencing femoral sizing guide was used to set femoral rotation and the anterior-posterior placement of the femoral anterior-posterior resection guide. After the posterior condylar cuts were performed, the resected specimens from the medial and lateral posterior condyles were collected (Fig. 2). Each condylar specimen was then sectioned in the midsagittal plane, and the thickness of the remaining cartilage was measured to the nearest millimeter with a hand-held ruler and recorded (Fig. 3). Preoperative limb alignment was determined for each knee based upon measurement of the mechanical axis from the center of the femoral head, to the center of the knee, to the center of the talus on full-length hip to ankle x-rays. Of the 145 knees, 6 did not have full length x-rays available for review. For the remaining 139 knees, 3 groups of patients were defined for statistical analysis based upon this preoperative mechanical axis measurement: valgus (4) 30 knees, neutral (3 to 3) 31 knees, varus (4) 78 knees. There were no external funding sources for this study.

Fig. 1. (A) True lateral radiograph demonstrating preoperative PCO (distance A). (B) True lateral radiograph demonstrating postoperative PCO (distance B).

performed between January 1, 2009, and January 31, 2010, were reviewed. In 6 patients who had undergone bilateral TKA, data from only 1 knee were used (the first side performed, which was the most symptomatic knee); furthermore, only data from the first knee in 7 patients

Statistical Methods
Spearman rank correlation was used to calculate the correlation between the thickness of the remaining

Fig. 2. Resected portions of the posterior femoral condyles obtained during TKA; lateral (L) and medial (m) specimens are noted.

Fig. 3. The resected portion of the posterior lateral femoral condyle has been split in the sagittal plane, and the thickness of the remaining articular cartilage is measured to the nearest millimeter.

Changes in PCO After TKA  Clarke Table 1. Distribution of Thickness of Remaining Cartilage on the Posterior Medial and Lateral Femoral Condyles in TKA
Thickness of Cartilage (mm) 0 1 2 3 4 5 Posterior Medial Femoral Condyle (No. of Knees) 28 32 47 32 5 0 Posterior Lateral Femoral Condyle (No. of Knees) 18 20 59 44 2 1

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cartilage on the medial and lateral posterior femoral condyles. Cartilage thickness was compared between patients with valgus, varus, and neutral alignment using the F test from a 1-way analysis of variance model. Pairwise comparisons between the groups were evaluated using the Tukey studentized range test to control the type I experiment wise error rate. All P values are 2 sided, and P b .05 was deemed statistically significant. SAS (version 9.1) statistical software (SAS Institute, Inc, Cary, NC) was used for the analysis.

Results
The mean cartilage thickness on the posterior medial femoral condyle was 1.7 mm (range, 0-4 mm) and, on the posterior lateral femoral condyle, was 2.0 mm (range, 0-5 mm). The distribution of the cartilage thickness is noted in Table 1. There was no significant correlation between the thickness of the remaining cartilage on the medial and lateral posterior femoral condyles (r = 0.08) (95% confidence interval, 0.24 to 0.09; P = .35) in the same patient, although there was a trend to an inverse correlation. Overall limb alignment on the full-length hip-to-ankle x-ray was correlated with the pattern of wear. Patients with valgus alignment had significantly thicker remaining cartilage on the posterior medial femoral condyle than both groups with either varus or neutral alignment (P b .05). Similarly, patients with varus alignment had significantly thicker cartilage on the posterior lateral femoral condyle than both groups with either valgus or neutral alignment (P b .05).

Discussion
The importance of restoring the PCO after TKA has been the source of continuing debate [10-18]. Bellemans et al [12] first hypothesized that overresection of the posterior condyles, resulting in a reduction of the PCO, would lead to impingement between the posterior aspect of the tibia and the posterior cortex of the femur [11]. This impingement, in turn, was postulated to result in a limitation of the maximal postoperative flexion that could be obtained [11,12]. In their original article on this subject, in which they studied a group of 150 patients who underwent TKA, Bellemans et al [12] noted that with a cruciate-retaining total knee prosthesis, for each

millimeter reduction in PCO, a mean reduction of 6.1 of flexion resulted postoperatively. Although reported to be a significant variable in determining the ultimate flexion that is obtained, other authors have reported varying magnitudes of this effect caused by changes in PCO. Massin and Gournay [11] reported that based upon a radiographic study, a 3-mm decrease in PCO could reduce flexion by 10. In distinction, Seo et al [18] were unable to identify a correlation between changes in PCO and postoperative flexion with a cruciate-retaining prosthesis. Moreover, the importance of PCO appears to be less significant in the presence of a posterior-stabilized or posterior-sacrificing knee prosthesis [14,15]. This is likely due to the kinematics and rollback being dictated by the prosthesis that reduces the risk of impingement, rather than being constrained by the native posterior cruciate ligament. Kim et al [14] reported no impact on postoperative flexion between 2 groups of patients who had undergone TKA with a posterior cruciate substituting knee prosthesis where 1 group had a 1.2-mm reduction in the PCO and the other group did not. Similar findings were reported by Hanratty et al [15] using a cruciate-sacrificing, mobilebearing prosthesis. Explanations for the controversy of the effect of changes in PCO may be due to the presence of other confounding variables including differences in the preoperative range of motion of the patients; whether posterior osteophytes were removed intraoperatively; and differences in tibial slope that were not controlled. Differences in the techniques used to measure changes in PCO may also play a role. Indeed, although similar radiographic techniques were used in these studies, the potential for systematic interobserver error exists and has not been adequately investigated. Inherent errors in the measurement techniques may also account for the inconsistent findings. The radiographic measurement of postoperative PCO can be readily determined, as the inferior most aspect of the posterior condyles of the metal femoral component can be accurately identified on the lateral radiograph. However, on the preoperative radiograph, the inferior aspect of the posterior condyles is assumed to be represented by the bony margin, whereas in most cases, there is some remaining cartilage. None of the prior studies have accounted for the thickness of the remaining cartilage on the posterior condyles. Variability in the thickness of this remaining cartilage would potentially render calculations of changes in PCO inaccurate, especially where changes of only 1 to 3 mm may have such a profound effect. No prior studies on the potential error introduced by variability in the remaining cartilage could be identified in the literature. In the present study, the variability of the remaining cartilage on the medial and lateral posterior femoral condyles was between 0 and 5 mm. Although there was a correlation between the

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preoperative mechanical axis of the limb and the remaining cartilage on the posterior condyle of the relatively unaffected compartment, with varus knees having thicker remaining lateral cartilage and valgus knees having thicker remaining medial cartilage, the loss of cartilage on both condyles in any given patient was not correlated. The variability of this remaining cartilage loss is certainly large enough to render radiographic measurements of changes in PCO unreliable; furthermore, the lack of correlation between cartilage loss in the medial and lateral condyles in any given patient means that it is difficult to accurately adjust the radiographic measurement of the preoperative PCO by a mean value to compensate for projected remaining cartilage. One final area of concern introduced by these findings pertains to evolving techniques in patient-specific instruments and prostheses manufacturing. Components that are individually manufactured for a specific patient based upon preoperative computed tomographic (CT) scans are being developed. Based upon the findings of this study, it is possible that, in some cases, suboptimal cartilage resolution on the CT may introduce anteroposterior sizing errors of up to 5 mm. This error is larger than the 3- or 4-mm incremental anteroposterior sizing differences that exist in many off the shelf knee prosthesis systems. This suggests that alternatives to CT-based modeling techniques should be considered. In summary, the variability of the remaining cartilage on the posterior femoral condyles demonstrated in the current study is of such a magnitude that any further studies on the effect of changes in PCO on postoperative flexion that are based upon differences in preoperative to postoperative lateral knee radiographs must account for the remaining cartilage. To accomplish this, the remaining cartilage thickness on the resected posterior condylar specimens must be measured intraoperatively for each patient, and this thickness should then be added to the bony thickness determined on the preoperative radiograph to calculate the composite preoperative PCO. This composite thickness can then be compared with the PCO measured on the postoperative radiograph.
3. McCalden RW, MacDonald SJ, Bourne RB, et al. A randomized controlled trial comparing High-Flex vs Standard posterior cruciate substituting polyethylene tibial inserts in total knee arthroplasty. J Arthroplasty 2009;24(6 Suppl):33. 4. Nutton RW, van der Linden ML, Rowe PJ, et al. A prospective randomized double-blind study of functional outcome and range of flexion following total knee replacement with the Nex Gen standard and high flexion components. J Bone Joint Surg Br 2008;90:37. 5. Victor J, Ries M, Bellemans J, et al. High-flexion, motion guided total knee arthroplasty: who benefits the most? Orthopedics 2007;30(8 Suppl):77. 6. Ginsel BL, Banks S, Verdonschot N, et al. Improving maximum flexion with a posterior cruciate retaining total knee arthroplasty: a fluoroscopic study. Acta Orthop Belg 2009;5:801. 7. Ritter MA, Harty LD, Davis KE, et al. Predicting range of motion after total knee arthroplasty clustering, log-linear regression, and regression tree analysis. J Bone Joint Surg Am 2003;85:1278. 8. Gatha NM, Clarke HD, Fuchs R, et al. Factors affecting post-operative range of motion after total knee arthroplasty. J Knee Surg 2004;17:196. 9. Mihalko W, Fishkin Z, Krakow K. Patellofemoral overstuff and its relationship to flexion after total knee arthroplasty. Clin Orthop Relat Res 2006;449:283. 10. Goldstein WM, Raab DJ, Gleason TF, et al. Why posterior cruciate-retaining and substituting total knee replacements have similar ranges of motion. J Bone Joint Surg 2006;88(Supplement 4):182. 11. Massin P, Gournay A. Optimization of the posterior condylar offset, tibial slope, and condylar roll-back in total knee arthroplasty. J Arthoplasty 2006;21:889. 12. Bellemans J, Banks S, Victor J, et al. Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty: influence of posterior condylar offset. J Bone Joint Surg Br 2002;84:50. 13. Arabori M, Matsui N, Kuroda R, et al. Posterior condylar offset and flexion in posterior cruciate-retaining and posterior stabilized TKA. J Orthop Sci 2008;13:46. 14. Kim YH, Sohn KS, Kim JS. Range of motion of standard and high-flexion posterior stabilized total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am 2005;87:1470. 15. Hanratty BM, Thompson NW, Wilson RK, et al. The influence of posterior condylar offset on knee flexion after total knee replacement using a cruciate-sacrificing mobilebearing implant. J Bone Joint Surg Br 2007;89:915. 16. Soda Y, Oishi J, Nakasa T, et al. New parameters of flexion after posterior stabilized total knee arthroplasty: posterior condylar offset ratio on x-ray. Acta Orthop Trauma Surg 2007;127:167. 17. Malviya A, Lingard EA, Weir DJ, et al. Predicting range of motion after knee replacement: the importance of posterior condylar offset and tibial slope. Knee Surg Sports Traumatol Arthrosc 2009;17:491. 18. Seo SS, Ha DJ, Kim CW, et al. Effect of posterior condylar offset on cruciate-retaining mobile TKA. Orthopedics 2009;32(10 Supplement):44.

Acknowledgments
I would like to thank Brie N. Noble, BS, Section of Biostatics, Mayo Clinic, Phoenix, Ariz, for her assistance with the statistical methods and analysis in this manuscript.

References
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