title: Posterior cruciate ligament balancing in total knee arthroplasty: a numerical study with a dynamic force controlled knee model.
abstract: BACKGROUND
  Adequate soft tissue balancing is a key factor for a successful result after total knee arthroplasty (TKA). Posterior cruciate ligament (PCL) is the primary restraint to posterior translation of the tibia after cruciate retaining TKA and is also responsible for the amount of joint compression. However, it is complex to quantify the amount of ligament release with its effects on load bearing and kinematics in TKA and limited both in vivo and in vitro. The goal of this study was to create a dynamic and deformable finite element model of a full leg and analyze a stepwise release of the PCL regarding knee kinematics, pressure distribution and ligament stresses.
  
  
  METHODS
  A dynamic finite element model was developed in Ansys V14.0 based on boundary conditions of an existing knee rig. A cruciate retraining knee prosthesis was virtually implanted. Ligament and muscle structures were simulated with modified spring elements. Linear elastic materials were defined for femoral component, inlay and patella cartilage. A restart algorithm was developed and implemented into the finite element simulation to hold the ground reaction force constant by adapting quadriceps force. After simulating the unreleased PCL model, two models were developed and calculated with the same boundary conditions with a 50% and 75% release of the PCL stiffness.
  
  
  RESULTS
  From the beginning of the simulation to approximately 35° of flexion, tibia moves posterior related to the femur and with higher flexion anteriorly. Anterior translation of the tibia ranged from 5.8 mm for unreleased PCL to 3.7 mm for 75% PCL release (4.9 mm 50% release).A decrease of maximum von Mises equivalent stress on the inlay was given with PCL release, especially in higher flexion angles from 11.1 MPa for unreleased PCL to 8.9 MPa for 50% release of the PCL and 7.8 MPa for 75% release.
  
  
  CONCLUSIONS
  Our study showed that dynamic FEM is an effective method for simulation of PCL balancing in knee arthroplasty. A tight PCL led in silico to more anterior tibia translation, a higher collateral ligament and inlay stress, while retropatellar pressure remained unchanged. Surgeons may take these results in vivo into account.
authors.affiliation: Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich (LMU), Campus Großhadern, Marchioninistraße 15, 81377 Munich, Germany. arnd.steinbrueck@med.uni-muenchen.de.
authors.forename: Arnd
authors.initials: A
authors.lastname: Steinbrück
authors.forename: Matthias
authors.initials: M
authors.lastname: Woiczinski
authors.forename: Patrick
authors.initials: P
authors.lastname: Weber
authors.forename: Peter Ernst
authors.initials: PE
authors.lastname: Müller
authors.forename: Volkmar
authors.initials: V
authors.lastname: Jansson
authors.forename: Christian
authors.initials: C
authors.lastname: Schröder
mesh_terms: D000328:Adult; D019645:Arthroplasty, Replacement, Knee; D001696:Biomechanical Phenomena; D020342:Finite Element Analysis; D006801:Humans; D007867:Leg Bones / Q000502:physiology; D008022:Ligaments; D008297:Male; D016119:Posterior Cruciate Ligament / Q000502:physiology; D011312:Pressure; D013312:Stress, Physiological; D016474:Weight-Bearing