title: Can a total knee arthroplasty be both rotationally unconstrained and anteroposteriorly stabilised? A pulsed fluoroscopic investigation.
abstract: OBJECTIVE
  Throughout the 20th Century, it has been postulated that the knee moves on the basis of a four-bar link mechanism composed of the cruciate ligaments, the femur and the tibia. As a consequence, the femur has been thought to roll back with flexion, and total knee arthroplasty (TKA) prostheses have been designed on this basis. Recent work, however, has proposed that at a position of between 0° and 120° the medial femoral condyle does not move anteroposteriorly whereas the lateral femoral condyle tends, but is not obliged, to roll back - a combination of movements which equates to tibial internal/ femoral external rotation with flexion. The aim of this paper was to assess if the articular geometry of the GMK Sphere TKA could recreate the natural knee movements in situ/in vivo.
  
  
  METHODS
  The pattern of knee movement was studied in 15 patients (six male: nine female; one male with bilateral TKAs) with 16 GMK Sphere implants, at a mean age of 66 years (53 to 76) with a mean BMI of 30 kg/m(2) (20 to 35). The motions of all 16 knees were observed using pulsed fluoroscopy during a number of weight-bearing and non-weight-bearing static and dynamic activities.
  
  
  RESULTS
  During maximally flexed kneeling and lunging activities, the mean tibial internal rotation was 8° (standard deviation (sd) 6). At a mean 112° flexion (sd 16) during lunging, the medial and lateral condyles were a mean of 2 mm (sd 3) and 8 mm (sd 4) posterior to a transverse line passing through the centre of the medial tibial concavity. With a mean flexion of 117° (sd 14) during kneeling, the medial and lateral condyles were a mean of 1 mm (sd 4) anterior and 6 mm (sd 4) posterior to the same line. During dynamic stair and pivoting activities, there was a mean anteroposterior translation of 0 mm to 2 mm of the medial femoral condyle. Backward lateral condylar translation occurred and was linearly related to tibial rotation.
  
  
  CONCLUSIONS
  The GMK Sphere TKA in our study group shows movements similar in pattern, although reduced in magnitude, to those in recent reports relating to normal knees during several activities. Specifically, little or no translation of the medial femoral condyle was observed during flexion, but there was posterior roll-back of the lateral femoral condyle, equating to tibiofemoral rotation. We conclude that the GMK Sphere is anteroposteriorly stable medially and permits rotation about the medial compartment.Cite this article: Professor G. Scott. Can a total knee arthroplasty be both rotationally unconstrained and anteroposteriorly stabilised?: A pulsed fluoroscopic investigation. Bone Joint Res 2016;5:80-86. DOI: 10.1302/2046-3758.53.2000621.
authors.affiliation: Trauma and Orthopaedic Department, Royal London Hospital, Whitechapel, London, E1 1BB, UK g.scott@qmul.ac.uk.
authors.forename: G
authors.initials: G
authors.lastname: Scott
authors.affiliation: South West London Elective Orthopaedic Centre, Epsom, UK.
authors.forename: M A
authors.initials: MA
authors.lastname: Imam
authors.affiliation: Department of Biomedical Engineering, University of Florida, Florida, USA.
authors.forename: A
authors.initials: A
authors.lastname: Eifert
authors.affiliation: Visiting Professor of Orthopaedics.
authors.forename: M A R
authors.initials: MA
authors.lastname: Freeman
authors.affiliation: Charles University, Prague, Czech Republic.
authors.forename: V
authors.initials: V
authors.lastname: Pinskerova
authors.affiliation: St Georges University of London, Director of Research, South West London Elective Orthopaedic Centre, Epsom, UK.
authors.forename: R E
authors.initials: RE
authors.lastname: Field
authors.affiliation: Royal National Orthopaedic Hospital, Stanmore, UK.
authors.forename: J
authors.initials: J
authors.lastname: Skinner
authors.affiliation: Department of Mechanical and Aerospace Engineering, University of Florida, Florida, USA.
authors.forename: S A
authors.initials: SA
authors.lastname: Banks
keywords: TKA; knee fluoroscopy; knee kinematics; total knee arthroplasty