Published online Aug 18, 2024. doi: 10.5312/wjo.v15.i8.764
Revised: July 1, 2024
Accepted: July 10, 2024
Published online: August 18, 2024
Processing time: 119 Days and 4.6 Hours
Total knee arthroplasty (TKA) using implants with a high level of constraint has generally been recommended for patients with osteoarthritis (OA) who have valgus alignment. However, studies have reported favorable outcomes even with cruciate-retaining (CR) implants.
To evaluate the coronal plane stability of CR-TKA in patients with valgus OA at the mid-term follow-up.
Patients with primary valgus OA of the knee who underwent TKA from January 2014 to January 2021 were evaluated through stress radiography using a digital stress device with 100 N of force on both the medial and lateral side. Gap open
This study included 25 patients (28 knees) with a mean preoperative mechanical valgus axis of 11.3 (3.6-27.3) degrees. The mean follow-up duration was 3.4 (1.04-7.4) years. Stress radiographs showed a median varus and valgus gap opening of 1.6 (IQR 0.6-3.0) mm and 1.7 (IQR 1.3-2.3) mm and varus and valgus angulation changes of 2.5 (IQR 1.3-4.8) degrees and 2.3 (IQR 2.0-3.6) degrees, respectively. No clinical signs of instability, implant loosening, or revision due to instability were observed throughout this case series.
The present study demonstrated that using CR-TKA for patients with valgus OA of the knee promoted excellent coronal plane stability.
Core Tip: Cruciate-retaining total knee arthroplasty (CR-TKA) for knee valgus osteoarthritis (OA) has been associated with high rates of postoperative tibiofemoral instability. Our study utilized a digital ligament stress device to objectively measure the coronal stability of CR-TKA in patients with knee valgus OA at a mean follow of 3 years and found no significant instability, with a median varus and valgus gap change of < 2 mm. All patients were satisfied with their knee without revision due to instability, loosening, or patellar-related complication. We also describe the step-by-step details of the surgical technique used to ensure good exposure and soft tissue balance.
- Citation: Chaiyakit P, Wattanapreechanon P. Coronal plane stability of cruciate-retaining total knee arthroplasty in valgus gonarthrosis patients: A mid-term evaluation using stress radiographs. World J Orthop 2024; 15(8): 764-772
- URL: https://www.wjgnet.com/2218-5836/full/v15/i8/764.htm
- DOI: https://dx.doi.org/10.5312/wjo.v15.i8.764
Approximately 10%-15% of patients with valgus alignment of the knee, defined as an anatomic valgus of the tibiofemoral axis exceeding 10 degrees, require total knee arthroplasty (TKA)[1,2]. Patients with valgus knees often present with various degrees of medial soft tissue insufficiency combined with tightness or contracture of the lateral soft tissue. Performing TKA in such patients seems to be associated with higher complication rates than performing TKA in patients with varus knees, especially in terms of tibiofemoral instability[3,4]. Various knee prosthesis constraints have been utilized during TKA of valgus knees, with the general recommendation being the use of at least posterior-stabilized (PS) TKA with post and cam design or constrained condylar design (constrained condylar knee) in cases with advance deformities and/or severe ligament insufficiency[5-8]. Cruciate-retaining (CR) TKA is the least constrained knee prosthesis that depends on the function of the posterior cruciate ligament to limit posterior translation of the tibia, with the prosthesis itself not providing varus-valgus stability[7,9]. Although some studies have shown good to excellence clinical results following CR-TKA in valgus knees[10-15], others have reported that around 10%-20% of patients develop varus-valgus instability[13,16]. Moreover, most studies have evaluated instability or laxity after TKA using manual clinical examination. Notably, Mears et al[17] demonstrated poor inter-rater reliability when clinically testing for both antero-posterior (AP) laxity in flexion and varus-valgus laxity. To the best of our knowledge, no study has yet objectively measured varus-valgus stability after performing CR-TKA among patients with valgus osteoarthritis (OA) of the knee. The current study therefore aimed to measure varus-valgus stability after performing CR-TKA patient with valgus OA of the knee using stress radiography combined with a digital ligament stress device.
This study was approved by the institutional review board committee of Navamindradhiraj University (COA157/2563). Informed consent was obtained from all patients prior to participation. We retrospectively reviewed data from patients with valgus OA (defined as a tibiofemoral axis greater than 10 degrees of valgus) admitted at our institution from January 2014-2021 who underwent primary CR-TKA performed by the senior author (Chaiyakit P). The exclusion criteria were secondary OA due to inflammatory joint disease or posttraumatic arthritis and a follow-up duration < 1 year after receiving index CR-TKA.
All patients underwent midvastus arthrotomy, followed by removal of the anterior cruciate ligament and osteophytes. We carefully preserved the medial soft tissues to prevent further iatrogenic laxity. The proximal tibia was resected perpendicular to its anatomical axis, guided by a conventional extramedullary device. Distal femur resection was guided by an intramedullary rod, with the valgus angle being set to 5 degrees in all cases. A spacer block and laminar spreader were used to evaluate the extension gap. If there was any asymmetry in the gaps with contracture of the lateral structures, a lateral release was performed with modification of lateral parapatellar arthrotomy[18] as shown in Figure 1. Normally, the lateral arthrotomy extends from 1 cm above the upper border of patella to just the medial side of Gerdy’s tubercle. After additional lateral arthrotomy, the contracted iliotibial band was released subperiosteally from Gerdy’s tubercle, and all lateral osteophytes on the femur and tibia were easily removed. The remaining contracted structure were released using the pie crusting technique with an 18 G needle and laminar spreader[1]. Moreover, in case of persistent tightness of the lateral structure causing an unbalanced extension gap, sliding lateral condylar osteotomy[19] was performed to correct it. Once a symmetrical extension gap was achieved, the flexion gap and femoral rotation can be addressed using soft tissue tension. The size of the femoral component was determined using the anterior referencing technique. An anterior cut, posterior cut, and chamfer cut of the femur were then performed. Thereafter, a trial reduction of both femoral and tibial components was conducted, with the tibial tray rotation being determined using the self-aligned technique[20]. Patellar tracking was assessed using the no-thumb technique in all cases, whereas extended release of the lateral structure, including the vastus lateralis, was performed as needed. Finally, all components were cemented, and the appropriate thickness of tibial polyethylene was inserted.
At the latest follow-up, all eligible patients underwent stress radiography in full extension with the use of a digital ligament stress device (Patent number 2101002860, Navamindradhiraj University, Bangkok, Thailand) as previously described by Kappel et al[21]. With the patient lying supine, a 100-N force was applied at the center of the knee (Figure 2), after which a true AP radiograph of the knee was obtained. Stress radiography was performed on both the medial and lateral sides of the knee to assess the integrity of the medial and lateral collateral ligaments. The gap opening in millimeters and degrees obtained from the stress radiograph were compared to those obtained from normal knee AP radiographs (Figure 3). Other radiographic parameters included the mechanical axis angles of the femur and tibia, alpha angle of femoral component, and beta angle of the tibial component[22]. We also carefully observed for radiographic signs of TKA loosening. All radiographic measurements were conducted independently by one of the authors (Wattanapreechanon P) and one trained personnel. Each investigator obtained two measurements, with a 2-week interval between each measurement, and calculated their average values. After assessing inter-rater reliability, the measurements from both investigators were averaged to report the results. The Thai version of the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire (WOMAC)[23], Knee Society score (KSS)[24], and Time Up and Go test (TUGT)[25] were utilized to evaluate the patients. Complications and revision surgery following the index surgery were thoroughly reviewed.
Descriptive statistical analysis of the data was conducted using Stata version 14.1. Continuous variables with a normal distribution were reported as mean and standard deviation, whereas those with a nonnormal distribution were reported as median and interquartile range. Categorical variables were expressed as frequencies and percentages. Inter-rater reliability of the radiographic measurements was evaluated by Cronbach’s alpha.
A total of 38 patients who were diagnosed with primary OA of the knee with valgus deformity underwent surgery from January 2014 to January 2021. Three patients were lost to follow-up during the last 3 years, whereas another three patients died of causes not associated with their knee condition. Although we were able to contact 32 patients, 7 declined to participate in the ligament stress test due to the circumstances surrounding the coronavirus disease 2019 (COVID-19) pandemic. All of them reported a well-functioning prosthesis without pain. Finally, 25 patients (28 knees) consented to participate in this study. Data for a total of 28 knees are summarized in Table 1. Accordingly, the average age of the included patients was 72 (72.6 ± 8) years old. The mean preoperative valgus mechanical axis deviation was 11.3 (range 3.6-27.3) degrees. Among the 27 knees that underwent valgus correction with the soft tissue procedure, only one needed lateral condylar sliding osteotomy (Figure 4). The mean follow-up duration was 3.4 (range 1.04-7.4) years. Our results showed that the Cronbach’s alpha values of all measurements indicated good agreement between both raters (Table 2). Therefore, all measurements from both raters were averaged. The stress radiograph showed a median varus gap opening of 1.6 (IQR 0.6-3.0) mm and 2.5 (IQR 1.3-4.8) degrees and a minimal valgus gap opening of 1.7 (IQR 1.3-2.3) mm and 2.3 (IQR 2.0-3.6) degrees. All patients were satisfied with their knees, which showed no clinical signs of instability, and did not report any patellar-related complications. None of the knees showed signs of radiographic loosening at the latest follow-up (Table 3).
Parameters | Values |
Age (years) | 72.6 (8.0)1 |
Sex, n (%) | |
Female | 24 (96.4) |
Side, n (%) | |
Right | 18 (64.2) |
BMI | 27.1 (3.3)1 |
ASA classification, n (%) | |
1 | 3 (10.7) |
2 | 23 (82.1) |
3 | 2 (7.1) |
Krackow classification, n (%) | |
1 | 21 (75) |
2 | 7 (5) |
Preop mechanical axis (degrees) | 11.31 (36-27.3) |
Preop tibial slope (degrees) | 9.0 (4.4)1 |
Prosthesis, n (%) | |
PFC sigma | 15 (53.6) |
NRG scorpio | 11 (39.3) |
Attune | 1 (3.5) |
Legion | 1 (3.5) |
Follow-up time (years) | 3.41 (Range 10-7.4) |
Parameters | Cronbach’s alpha |
Preop mechanical axis (degrees) | 0.981 |
Postop mechanical axis (degrees) | 0.820 |
Preop tibial slope (degrees) | 0.802 |
Postop tibial slope (degrees) | 0.929 |
Varus gap opening (mm) | 0.964 |
Varus gap opening (degrees) | 0.972 |
Valgus gap opening (mm) | 0.821 |
Valgus gap opening (degrees) | 0.921 |
Alpha angle (degrees) | 0.819 |
Beta angle (degrees) | 0.757 |
Parameters | Values |
Postop mechanical axis (degrees) (negative value represents varus angle) | 0.4 (-0.4 to 2.3)2 |
Postop tibial slope (degrees) | 3.7 (2.4-7.1)2 |
Alpha angle (degrees) | 93.7 (2.1)1 |
Beta angle (degrees) | 89.6 (1.0)1 |
Varus gap opening (mm) | 1.6 (0.6-3.0)2 |
Varus gap opening (degrees) | 2.5 (1.3-4.8)2 |
Valgus gap opening (mm) | 2.0 (1.6-2.3)2 |
Valgus gap opening (degrees) | 2.3 (2.0-3.6)2 |
Through the operative technique described earlier, we were able to achieve immediate intra- and postoperative stability in all cases. Among the knees examined in this series, 17 (60.7%) were implanted with the least thick polyethylene insert available, resulting in a combined tibial thickness of < 13 mm (Figure 5). The median total WOMAC score was 20.5 (IQR 17-48), the median KSS knee score was 91.5 (85-94.5), the mean KSS function score was 71.6 ± 22.7, and the median TUGT was 13 (IQR 11.5-18.5) s (Table 4). The mean flexion ROM was 113.9 ± 12.6 degrees, whereas the mean extension ROM was 1.9 ± 3.9 degrees. Reoperation was required in two knees (two patients). The first case was diagnosed with acute hematogenous periprosthetic joint infection 1 year after the index surgery, which was successfully treated with arthrotomy debridement and polyethylene exchange combined with intra-articular infusion of antibiotics[26]. The second case presented with early postoperative wound dehiscence, which required simple re-suturing.
Some studies have shown that CR-TKA provided poor results for patients with valgus OA of the knee, which has prompted guidelines to generally recommend the use of PS-TKA for the management of valgus knees. Notably, Savov et al[16], who evaluated 248 patients who underwent TKA for valgus OA of the knee, found no significant differences in clinical outcomes between the CR and PS-TKA groups. However, they found that 8.0% of the patients in the CR-TKA group required reoperation due to instability, whereas none of those in the PS-TKA group required the same. Koskinen et al[13] also reported the need for early revisions following CR-TKA in patients with severe valgus OA of the knee, with 8 out of 52 knees (15%) in their series requiring revision surgery due to medial instability. However, PS-TKA is not as effective as CR-TKA in improving varus-valgus stability given that its post and cam mechanism was designed to improve AP stability during flexion. One report even showed a higher percentage of mid-flexion laxity after PS-TKA than after CR-TKA[27,28]. Ang et al[11] reported that both CR- and PS-TKA exhibited comparable postoperative clinical outcomes and coronal plane laxity observed during physical examination in patients with type 2 valgus OA of the knees.
The current study was designed to evaluate postoperative coronal plane stability using a digital stress device, which allows for the accurate measurement of forces placed on the knee. One trained personnel was responsible for imp
The present study has been the first to provide an objective medio-lateral laxity measurement after CR-TKA in patients with valgus OA of the knee. Our results also showed that CR-TKA promoted favorable clinical outcomes based on the WOMAC score, KSS score, and TUGT, with no instability or loosening observed. However, some limitations of the current study need to be addressed. First, we could not evaluate coronal plane laxity in the knee flexion position and sagittal plane laxity. This is due to a lack of reliable diagnostic tools available at our institution. Second, we only included patients with a diagnosis of primary knee OA. For patients with secondary knee OA, the quality of the ligament, especially the posterior cruciate ligament, is usually not reliable, which could be insufficient at the time of operation or could stretch over time. Finally, the number of participants is quite limited, partly due to the COVID-19 pandemic.
Adequate exposure and meticulous soft tissue release are crucial for obtaining good clinical outcomes after TKA. Overall, our findings showed that the least constrained knee prosthesis, namely CR-TKA, could be utilized provided that excellent gap balance was achieved. The present study demonstrated that with good exposure and adequate soft tissue balance, CR-TKA could achieve excellent coronal stability and clinical outcomes when used for managing valgus OA of the knee.
The authors would like to thank Thanapat Pakecheep, M.D. for his contribution in the radiographic measurements.
1. | Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am. 2005;87 Suppl 1:271-284. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 34] [Cited by in F6Publishing: 88] [Article Influence: 4.6] [Reference Citation Analysis (1)] |
2. | Stern SH, Moeckel BH, Insall JN. Total knee arthroplasty in valgus knees. Clin Orthop Relat Res. 1991;5-8. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 49] [Cited by in F6Publishing: 49] [Article Influence: 1.5] [Reference Citation Analysis (0)] |
3. | Nikolopoulos DD, Polyzois I, Apostolopoulos AP, Rossas C, Moutsios-Rentzos A, Michos IV. Total knee arthroplasty in severe valgus knee deformity: comparison of a standard medial parapatellar approach combined with tibial tubercle osteotomy. Knee Surg Sports Traumatol Arthrosc. 2011;19:1834-1842. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 31] [Cited by in F6Publishing: 32] [Article Influence: 2.5] [Reference Citation Analysis (0)] |
4. | Favorito PJ, Mihalko WM, Krackow KA. Total knee arthroplasty in the valgus knee. J Am Acad Orthop Surg. 2002;10:16-24. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 80] [Cited by in F6Publishing: 72] [Article Influence: 3.3] [Reference Citation Analysis (0)] |
5. | Anderson JA, Baldini A, MacDonald JH, Pellicci PM, Sculco TP. Primary constrained condylar knee arthroplasty without stem extensions for the valgus knee. Clin Orthop Relat Res. 2006;442:199-203. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 66] [Cited by in F6Publishing: 65] [Article Influence: 3.6] [Reference Citation Analysis (0)] |
6. | Easley ME, Insall JN, Scuderi GR, Bullek DD. Primary constrained condylar knee arthroplasty for the arthritic valgus knee. Clin Orthop Relat Res. 2000;58-64. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 119] [Cited by in F6Publishing: 90] [Article Influence: 3.8] [Reference Citation Analysis (0)] |
7. | Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg. 2005;13:515-524. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 112] [Cited by in F6Publishing: 100] [Article Influence: 5.3] [Reference Citation Analysis (0)] |
8. | Lange J, Haas SB. Correcting severe valgus deformity: taking out the knock. Bone Joint J. 2017;99-B:60-64. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 20] [Cited by in F6Publishing: 20] [Article Influence: 2.9] [Reference Citation Analysis (0)] |
9. | McAuley JP, Engh GA. Constraint in total knee arthroplasty: when and what? J Arthroplasty. 2003;18:51-54. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 59] [Cited by in F6Publishing: 65] [Article Influence: 3.1] [Reference Citation Analysis (0)] |
10. | Ritter MA, Faris GW, Faris PM, Davis KE. Total knee arthroplasty in patients with angular varus or valgus deformities of > or = 20 degrees. J Arthroplasty. 2004;19:862-866. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 43] [Cited by in F6Publishing: 40] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
11. | Ang CL, Fook S, Chia SL, Chin PL, Lo NN, Yeo SJ. Unconstrained arthroplasty in type II valgus knees: posterior stabilized or cruciate retaining? Knee Surg Sports Traumatol Arthrosc. 2014;22:666-673. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 7] [Cited by in F6Publishing: 8] [Article Influence: 0.8] [Reference Citation Analysis (0)] |
12. | Kubiak P, Archibeck MJ, White RE Jr. Cruciate-retaining total knee arthroplasty in patients with at least fifteen degrees of coronal plane deformity. J Arthroplasty. 2008;23:366-370. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 19] [Cited by in F6Publishing: 19] [Article Influence: 1.2] [Reference Citation Analysis (0)] |
13. | Koskinen E, Remes V, Paavolainen P, Harilainen A, Sandelin J, Tallroth K, Kettunen J, Ylinen P. Results of total knee replacement with a cruciate-retaining model for severe valgus deformity--a study of 48 patients followed for an average of 9 years. Knee. 2011;18:145-150. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 21] [Cited by in F6Publishing: 21] [Article Influence: 1.6] [Reference Citation Analysis (0)] |
14. | McAuley JP, Collier MB, Hamilton WG, Tabaraee E, Engh GA. Posterior cruciate-retaining total knee arthroplasty for valgus osteoarthritis. Clin Orthop Relat Res. 2008;466:2644-2649. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 31] [Cited by in F6Publishing: 32] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
15. | Rajgopal A, Dahiya V, Vasdev A, Kochhar H, Tyagi V. Long-term results of total knee arthroplasty for valgus knees: soft-tissue release technique and implant selection. J Orthop Surg (Hong Kong). 2011;19:60-63. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 26] [Cited by in F6Publishing: 28] [Article Influence: 2.2] [Reference Citation Analysis (0)] |
16. | Savov P, Mielke E, Windhagen H, Calliess T, Richter A, Ettinger M. Higher revision rate for posterior cruciate-retaining than posterior-stabilized total knee arthroplasty for the treatment of valgus osteoarthritis. Arch Orthop Trauma Surg. 2021;141:305-312. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 4] [Cited by in F6Publishing: 6] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
17. | Mears SC, Severin AC, Wang J, Thostenson JD, Mannen EM, Stambough JB, Edwards PK, Barnes CL. Inter-Rater Reliability of Clinical Testing for Laxity After Knee Arthroplasty. J Arthroplasty. 2022;37:1296-1301. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1] [Reference Citation Analysis (0)] |
18. | Keblish PA. The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over two-year follow-up evaluation. Clin Orthop Relat Res. 1991;52-62. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 97] [Cited by in F6Publishing: 97] [Article Influence: 2.9] [Reference Citation Analysis (0)] |
19. | Brilhault J, Lautman S, Favard L, Burdin P. Lateral femoral sliding osteotomy lateral release in total knee arthroplasty for a fixed valgus deformity. J Bone Joint Surg Br. 2002;84:1131-1137. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 44] [Cited by in F6Publishing: 50] [Article Influence: 2.3] [Reference Citation Analysis (0)] |
20. | Ikeuchi M, Yamanaka N, Okanoue Y, Ueta E, Tani T. Determining the rotational alignment of the tibial component at total knee replacement: a comparison of two techniques. J Bone Joint Surg Br. 2007;89:45-49. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 60] [Cited by in F6Publishing: 67] [Article Influence: 3.9] [Reference Citation Analysis (0)] |
21. | Kappel A, Mortensen JF, Nielsen PT, Odgaard A, Laursen M. Reliability of stress radiography in the assessment of coronal laxity following total knee arthroplasty. Knee. 2020;27:221-228. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 7] [Cited by in F6Publishing: 8] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
22. | Bach CM, Steingruber IE, Peer S, Nogler M, Wimmer C, Ogon M. Radiographic assessment in total knee arthroplasty. Clin Orthop Relat Res. 2001;144-150. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 37] [Cited by in F6Publishing: 37] [Article Influence: 1.6] [Reference Citation Analysis (0)] |
23. | Kuptniratsaikul V, Rattanachaiyanont M. Validation of a modified Thai version of the Western Ontario and McMaster (WOMAC) osteoarthritis index for knee osteoarthritis. Clin Rheumatol. 2007;26:1641-1645. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 34] [Cited by in F6Publishing: 37] [Article Influence: 2.2] [Reference Citation Analysis (0)] |
24. | Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;13-14. [PubMed] [Cited in This Article: ] |
25. | Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-148. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 8741] [Cited by in F6Publishing: 8754] [Article Influence: 265.3] [Reference Citation Analysis (0)] |
26. | Chaiyakit P, Meknavin S, Hongku N, Onklin I. Debridement, antibiotics, and implant retention combined with direct intra-articular antibiotic infusion in patients with acute hematogenous periprosthetic joint infection of the knee. BMC Musculoskelet Disord. 2021;22:557. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 2] [Cited by in F6Publishing: 3] [Article Influence: 1.0] [Reference Citation Analysis (0)] |
27. | Woodard E, Williams J, Mihalko W. Laxity differences in cruciate-retaining and posterior-stabilised total knee arthroplasty. Orthopaedic Proc. 2016;98-B Suppl 4:127. [Cited in This Article: ] |
28. | Hino K, Ishimaru M, Iseki Y, Watanabe S, Onishi Y, Miura H. Mid-flexion laxity is greater after posterior-stabilised total knee replacement than with cruciate-retaining procedures: A computer navigation study. Bone Joint J. 2013;95-B:493-497. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 53] [Cited by in F6Publishing: 57] [Article Influence: 5.2] [Reference Citation Analysis (0)] |
29. | Ishii Y, Matsuda Y, Ishii R, Sakata S, Omori G. Coronal laxity in extension in vivo after total knee arthroplasty. J Orthop Sci. 2003;8:538-542. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 33] [Cited by in F6Publishing: 33] [Article Influence: 1.6] [Reference Citation Analysis (0)] |
30. | Murer M, Falkowski AL, Hirschmann A, Amsler F, Hirschmann MT. Threshold values for stress radiographs in unstable knees after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2021;29:422-428. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 13] [Cited by in F6Publishing: 15] [Article Influence: 5.0] [Reference Citation Analysis (0)] |