Pelvic incidence (PI) is a position-independent spinopelvic parameter traditionally used by spinal surgeons to determine spinal alignment. Its relevance to the arthroplasty surgeon in assessing patient risk for total hip arthroplasty (THA) instability preoperatively is unclear. This study was undertaken to investigate the significance of PI relative to other spinopelvic parameter risk factors for instability to help guide its clinical application. Retrospective analysis was performed of a multicentre THA database of 9,414 patients with preoperative imaging (dynamic spinopelvic radiographs and pelvic CT scans). Several spinopelvic parameter measurements were made by engineers using advanced software including sacral slope (SS), standing anterior pelvic plane tilt (APPT), spinopelvic tilt (SPT), lumbar lordosis (LL), and PI. Lumbar flexion (LF) was determined by change in LL between standing and flexed-seated lateral radiographs. Abnormal pelvic mobility was defined as ∆SPT ≥ 20° between standing and flexed-forward positions. Sagittal spinal deformity (SSD) was defined as PI-LL mismatch > 10°.Aims
Methods
Cross-table lateral (CTL) radiographs are commonly used to measure acetabular component anteversion after total hip arthroplasty (THA). The CTL measurements may differ by > 10° from CT scan measurements but the reasons for this discrepancy are poorly understood. Anteversion measurements from CTL radiographs and CT scans are compared to identify spinopelvic parameters predictive of inaccuracy. THA patients (n = 47; 27 males, 20 females; mean age 62.9 years (SD 6.95)) with preoperative spinopelvic mobility, radiological analysis, and postoperative CT scans were retrospectively reviewed. Acetabular component anteversion was measured on postoperative CTL radiographs and CT scans using 3D reconstructions of the pelvis. Two cohorts were identified based on a CTL-CT error of ≥ 10° (n = 11) or < 10° (n = 36). Spinopelvic mobility parameters were compared using independent-samples Aims
Methods
Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty. Patients undergoing revision for PJI may experience considerable psychological distress and symptoms of depression, both of which are linked to poor post-operative outcomes. We therefore aim to identify the prevalence of depressive symptoms in patients prior to treatment for PJI. All patients between September 2008 – October 2018 undergoing single or 2-stage revision for PJI with minimum 1-year follow-up were retrospectively reviewed at a single institution. The 2-stage (n=37) and single stage (n=39) patients that met inclusion criteria were matched based off age (+/−5), gender and BMI (+/−5) to patients undergoing aseptic revisions. Based on prior literature, patients were considered to have depressive symptoms if their VR-12 mental component score (MCS) was below 42. Using Student's t-tests, outcomes evaluated included pre-operative and 1-year post-operative VR-12 MCS and physical component scores (PCS).Introduction
Methods
Surgical management of PJI remains challenging with patients failing treatment despite the best efforts. An important question is whether these later failures reflect reinfection or the persistence of infection. Proponents of reinfection believe hosts are vulnerable to developing infection and new organisms emerge. The alternative hypothesis is that later failure is a result of an organism that was present in the joint but was not picked up by initial culture or was not a pathogen initially but became so under antibiotic pressure. This multicenter study explores the above dilemma. Utilizing next-generation sequencing (NGS), we hypothesize that failures after two stage exchange arthroplasty can be caused by an organism that was present at the time of initial surgery but not isolated by culture. This prospective study involving 15 institutions collected samples from 635 revision total hip (n=310) and knee (n=325) arthroplasties. Synovial fluid, tissue and swabs were obtained intraoperatively for NGS analysis. Patients were classified per 2018 Consensus definition of PJI. Treatment failure was defined as reoperation for infection that yielded positive cultures, during minimum 1-year follow-up. Concordance of the infecting pathogen cultured at failure with NGS analysis at initial revision was determined.Introduction
Methods
Cross table lateral (CTL) radiographs are commonly used to measure acetabular component anteversion after total hip arthroplasty (THA). CTL measurements may differ by >10 degrees from CT scan measurements, but the reasons for this discrepancy are poorly understood. We compare anteversion measurements made on CTL radiographs and CT scans to identify spinopelvic parameters predictive of inaccuracy. THA patients (n=47) with preoperative spinopelvic radiographic analysis and postoperative CT scans were retrospectively reviewed. Acetabular component anteversion was measured on post-operative CTL radiographs, and CT scans using 3D reconstructions of the pelvis. Patients were grouped by error (CTL-CT)>10° (n=11) or <10° (n=36), and spinopelvic mobility parameters were compared using t-tests. Correlation between error and mobility parameters was assessed with Pearson coefficient.Introduction
Methods
Of growing concern in arthroplasty is the emergence of atypical infections, particularly For this non-randomized non-blinded study, 101 adult patients scheduled for hip or knee surgery were recruited. For each, four 3 mm dermal punch biopsies were collected after administration of anaesthesia, but prior to antibiotics. Prebiopsy skin preparation consisted of a standardized preoperative 2% chlorhexidine skin cleansing protocol and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two skin samples 10 cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10 cm apart were collected from a lateral skin incision (suitable for posterior, direct-lateral, or anterolateral approaches). Samples were cultured for two weeks using a protocol optimized for Aims
Methods
Cutibacterium acnes (C. acnes) is now recognized as a clinical entity in periprosthetic joint infections (PJI) of the shoulder and spine. However, the colonization rate of C. acnes in the adult hip is currently unknown. Therefore, the purpose of this study was to investigate the rate of C. acnes colonization from the skin of healthy subjects from various anatomic locations corresponding to direct anterior and lateral/posterolateral surgical approaches. 90 patients scheduled for hip or knee surgery were recruited for cultured biopsies. Four 3-mm dermal punch biopsies were collected after administration of anesthesia, but prior to delivery of perioperative antibiotics. Pre-biopsy skin prep consisted of a standardized pre-operative 2% chlorhexidine skin cleanse and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two culture samples 10-cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10-cm apart were collected from a location approximating a lateral skin incision (suitable for a posterior, direct-lateral or anterolateral surgical approach). Samples were cultured for two weeks.Introduction
Methods
Optimal perioperative fluid management has not been established in patients undergoing orthopaedic surgical procedures. Our purpose was to investigate the effects of perioperative fluid management on patients experiencing TKA. One hundred thirty patients who met inclusion criteria undergoing primary unilateral TKA were prospectively randomized into traditional (TFG) vs. oral (OFG) perioperative fluid management groups. The TFG had a predetermined (4L) amount of intravenous fluids (IVF) administered in the perioperative period. The OFG began drinking a minimum of three, 20-ounces servings of clear fluids daily for three days prior to surgery. This cohort also drank 10-ounces of clear fluids 4 hours prior to surgery. Perioperative IVF were discontinued when the patient began oral intake or when the total amount of IVF reached 500mL. Outcome measures included: body-weight (BW) fluctuations, knee motion, leg girth, bioelectrical impendence, quadriceps activation, functional outcomes testing, KOOS JR, VR-12, laboratory values, vital signs, patient satisfaction, pain scores, and adverse events.Background
Methods
The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications. A total of 29 patients undergoing simultaneous bilateral total knee arthroplasty (TKA) were enrolled in a prospective, randomized blinded study. Patients were randomized to receive a CSD in one limb while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction (‘sham drain’). Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps activation, intra-articular effusion measured via ultrasound, lower limb swelling measured with bioelectrical impendence and limb girth, knee ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day two, two and six weeks, and three months. Differences between limbs were determined using paired Student’s Aims
Patients and Methods
Closed suction intraarticular drain (CSD) use after total knee arthroplasty (TKA) has been studied with regards to wound healing and range of motion, however, no data exist on how CSD use impacts knee joint effusion and quadriceps strength. The primary purpose of this study was to determine whether CSD use influences recovery of quadriceps strength. Secondary outcomes examined effects of CSD on intraarticular effusion, lower limb swelling, knee range of motion (ROM), pain and wound healing complications. Twenty-nine patients undergoing same-day bilateral TKA were enrolled in a prospective, randomized blinded study. Subjects were randomized to receive a CSD on one lower extremity while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction. Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps muscle activation, intraarticular effusion measured via ultrasound, lower extremity swelling measured with bioelectrical impendence, lower extremity girth, ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day 2, 2 and 6 weeks and 3 months. Differences in limbs were determined using paired t-tests or Wilcoxon signed rank tests.Introduction
Methods
All over the world, obesity rates are on the rise. Medical complications and increased health risks are often associated with being overweight or obese, but a thorough understanding of in vivo motions for obese, overweight and normal weight subjects does not exist. Therefore, the objective of this study was to compare knee kinematics in TKA subjects by body mass index (BMI). In vivo knee kinematics were determined for 253 TKA subjects during a Deep Knee Bend (DKB) from full extension to maximum flexion using a 3D to 2D image registration technique. Each of these subjects was then classified into one of three BMI categories: obese (BMI greater than or equal to 30), overweight (BMI greater than or equal to 25 and less than 30) and normal weight (BMI less than 25 and greater than or equal to 18.5). Subjects were provided by 11 surgeons using ten different TKA devices. All subjects were deemed clinically successful. On average, weight bearing range of motion (ROM) for the obese (n=79), overweight (n=113) and normal weight (n=61) groups were 107.7° (range: 74° to 136°, standard deviation (σ) =14.9°), 109.6° (60° to 150°, σ=17.5°) and 114.1° (72° to 147°, σ=14.4), respectively. ROM of 90° or less was seen in 16.5% of the obese subjects, 14.2% of the overweigh subjects and 6.6% of the normal weight subjects. ROM of 125° or more was seen in 15.2% of the obese subjects, 16.8% of the overweight subjects and 23.0% of the normal weight subjects. From full extension to maximum flexion the obese, overweight and normal weight groups averaged 8.65° (−5.14° to 22.51°, σ=6.22°), 7.58° (−2.85° to 24.72°, σ=5.71°) and 5.72° (−4.84° to 19.43°, σ=5.65°) of axial rotation. Axial rotation of 3° or less was seen in 20.25% of the obese subjects, 23.01% of the overweight subjects and 39.34% of the normal weight subjects. Axial rotation of greater than 9° was seen in 51.90% of the obese subjects, 35.40% of the overweight subjects and 26.23% of the normal weight subjects. Opposite axial rotation was seen in 8.86% of the subjects in the obese group, 9.73% of the overweight group and 9.84% of the normal weight group. On average, from full extension to maximum flexion, the medial condyle for the obese, overweight and normal weight groups experienced −5.44mm (−22.20mm to 8.04mm, σ=7.9mm), −6.30mm (−25.22mm to 5.35mm, σ=7.36mm) and −4.78mm (−20.79mm to 5.49mm, σ=6.68mm) of posterior femoral rollback (PFR), respectively. The obese, overweight and normal weight groups averaged −12.66 mm (−34.57mm to 0.34mm, σ=9.32mm), −12.38mm (−36.72mm to 1.83mm, σ=10.33mm) and −9.39 mm (−34.55mm to 0.35mm, σ=8.98mm) of lateral PFR, respectively. Condylar lift-off of greater than 1mm was seen in 16.46% of obese subjects, 10.62% of overweight subjects and 11.48% of normal weight subjects. Various statistical differences were seen across the groups. The normal weight subjects had significantly higher ROM that the obese subjects (p=0.0184), while there was no difference seen between the normal weight and overweight groups or the overweight and obese groups. The obese and the overweight groups had significantly more axial rotation than the normal weight group from 0° to 90°, 0° to maximum flexion, 30° to 90°, 30° to maximum flexion and 60° to 90°. There were a significantly higher number of cases of condylar lift-off for obese subjects when compared to both normal weight and overweight groups. It can be concluded that body mass index does play a factor in TKA kinematics.
An institution of the authors (Center for Musculoskeletal Research) and one author (DAD) have received funding from DePuy, Inc. (Warsaw, IN). Each author certifies that his or her institution has approved the reporting of these cases, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at Center for Musculoskeletal Research, University of Tennessee, Knoxville, TN and the Rocky Mountain Musculoskeletal Research Laboratory, Denver, CO.
Previous clinical studies have documented the incidence of squeaking in subjects having a ceramic-onceramic (COC) THA. An in vivo sound sensor was recently developed used to capture sound at the THA interface. In this first study, it was determined that subjects having all bearing surface types demonstrated variable sounds. Therefore, in this follow-up study, the overall objective was to simultaneously capture in vivo sound and motion of the femoral head within the acetabular cup during weight-bearing activities for subjects implanted with one of four different ceramic-on-ceramic (COC) THA. Twenty subjects, each implanted with one of four types of Ceramic-on-Ceramic THA (9 Smith and Nephew, 8 Stryker, 2 Wright Medical Technologies and 1 Encore) were analyzed under in vivo, weightbearing conditions using video fluoroscopy and a sound sensor while performing gait on a treadmill. Patients were pre-screened and two groups were defined: a group diagnosed as audible squeakers (9 THAs) and a control group of THA patients not experiencing audible sounds (11 THAs). Two tri-axial piezoelectric accelerometers were attached to the pelvis and the femoral bone prominences respectively. The sensors detect frequencies propagating through the hip joint interaction. Also, 3D kinematics of the hip joint was determined, with the help of a previously published 2D-to-3D registration technique. In vivo sound was then correlated to 3D in vivo kinematics to determine if positioning of the femoral head within the acetabular cup is an influencing factor. For the audible group, two had a Smith and Nephew (S&
N) THA, six a Stryker THA and one a Wright Medical (WMT) THA. Both of the S&
N subjects, 5/6 Stryker and the Wright Medical subjects experienced femoral head separation. The maximum separation for those subjects was 4.6, 5.0 and 2.1 mm for the S&
N, Stryker and WMT subjects, respectively. The average separation was 4.3, 2.0 and 2.1 mm for the S&
N, Stryker and WMT subjects, respectively. For the eleven subjects in the control group, seven subjects had a S&
N THA, two a Stryker and one each having a WMT and Encore THA. All 11 of these subjects demonstrated hip separation with the maximum values being 3.8, 3.4, 1.9 and 2.4 mm for the S&
N, Stryker, WMT and Encore THA, respectively. The average separation values were 1.8, 2.3, 1.9 and 2.4 mm for the S&
N, Stryker, WMT and Encore THA subjects, respectively. Four distinct sounds were produced by subjects in this study, which were squeaking, knocking, clicking and grating. Only 3/20 subjects produced a “squeaking” sound that was detected using our sound sensor. One of these subjects had a Stryker THA and two had a WMT THA. Further analysis of the nine subjects who were categorized as audible squeakers revealed that only 0/2, 1/6 and 1/1 subjects having a S&
N, Stryker and WMT THA, respectively, demonstrated a squeaking sound that was detected using our sound sensor. Both (2/2) S&
N subjects demonstrated a knocking and clicking sound, but neither produced a grating sound, while 5/6 Stryker subjects produced a knocking sound, but only 1/6 demonstrated a clicking or grating sound. Besides the squeaking sound, the only other sound produced by the WMT audible squeaker was a knocking sound. Only 1/11 control group subjects demonstrated a squeaking sound, which was a subject having a WMT THA. With respect to the control group subjects having a S&
N THA, 5/7, 1/7 and 3/7 subjects produced a knocking, clicking or grating sound, respectively. Only 1/2 subjects having a Stryker THA produced a knocking or grating sound. This is the first study to compare multiple COC THAs in analyzing correlation of femoral head separation (sliding) and sound. It was seen that all the THA groups had occurrences of separation and each case of separation correlated with the sound data. These results lead the authors to believe that the influence of squeaking is multi-factorial, and not necessarily attributed only to the bearing surface material.
Polyethylene debris can cause patient osteolysis, patient pain and discomfort, and implant revision. Previous fluoroscopic studies have determined the incidence of femoral head separation from the acetabular cup, but clinical significance of this phenomenon has not been established. It has been hypothesized that hip separation may lead to polyethylene wear, while others hypothesize that hip separation may be occurring due to wear. Therefore, the purpose of the study is to conduct an in vivo kinematic analysis to determine if there is a correlation between-femoral head separation and wear and to utilize a mathematical modeling to determine the clinical significance of these variables. Twenty subjects were strategically selected to participate in this study. Ten subjects were determined to have at least1.0 mm of polyethylene wear, while ten subjects had less than 0.1 mm of polyethylene wear. All 20 patients were asked to perform gait on a treadmill while under fluoroscopic surveillance. The incidence of femoral head separation was determined for each subject. Then, a three-dimensional mathematical model of the hip joint was used to determine bearing surface conditions for each subject. Fifty-five percent of the subjects evaluated demonstrated femoral head separation. Subjects deemed to have greater than 1.0 mm of wear experienced less separation, on average and overall magnitude than subjects without wear. In this study, only 10% of the subjects tested-demonstrated no wear and no separation. The derived force profiles in this study were greater for both groups, compared with the non-implanted hips, previously evaluated. The forces in the hip joint ranged from 2.0 to 3.0times body weight. Although it was expected that subjects having more wear would have greater magnitudes of femoral head separation, the opposite was true. Further kinetic analysis determined that the subjects having wear also experienced greater force profiles through gait. Therefore, it is assumed that the subjects having wear may have been-implanted with a tighter socket, thus leading to greater shear forces.
The objective of this study was to compute the in vivo dynamic tibiofemoral contact forces for normal alignment, and then evaluate the change in contact forces and pressures with increasing varus-valgus and internal-external rotational malalignment of the femoral component. A three-dimensional computational model of the lower limb during deep knee bend was created using Kane’s method of dynamics. The change in forces from normal with malalignment of up to 10° valgus, 10° varus, 10° internal axial femoral rotation, and 10° internal axial femoral rotation were determined. In this study, varus-valgus malalignment had the greatest effect on medial-lateral pattelofemoral contact forces, with a maximum increase of 2.25 times body weight for 10° valgus malalignment. Axial malalignment had the greatest influence on tibiofemoral contact forces.
At present, contact stress analyses of TKA involve in vitro experimental testing. The objective of this project was to develop a parametric mathematical model that determines in vivo contact stresses for subjects implanted with a TKA, under in vivo, dynamic conditions. It is hypothesized that the results from this model will be more representative of in vivo conditions, thus leading to more accurate prediction of TKA bearing surface stresses. In vivo kinematics were determined for ten subjects implanted with a posterior stabilized TKA during gait and a deep knee bend under fluoroscopic surveillance. Three-dimensional contact positions, determined between the femoral component and the polyethylene insert, were entered into a complicated mathematical model to determine bearing surface forces. In vivo kinematics and kinetics were entered into a deformation model to predict in vivo contact areas between the medial and lateral condyles and tibial insert. The orientation of the femoral and tibial components, the predicted in vivo contact areas, and vectoral information of soft-tissue derived from MRI images were then entered into a mathematical model that predicted in vivo contact stresses between the femoral component and the tibial insert. This is the first computational model that utilizes fluoroscopy, MRI, deformation characteristics and Kane’s theory of Dynamics to predict in vivo contact stresses. Although previous models have not been validated, this model was validated by comparing the predicted foot/ ground force with the experimentally derived force. This study demonstrates that patellar motion influences forces throughout the lower extremity. The in vivo contact stress values predicted in this initial study were less than the yield strength of polyethylene.
Numerous dynamic studies have evaluated the tibiofemoral contact pressures that follow total knee arthroplasty (TKA), and several static studies utilizing finite elements and pressure sensitive film have evaluated malalignment. The objective of this study was to compute the in vivo dynamic tibiofemoral contact forces for normal alignment and evaluate the change in contact pressure with increasing malalignment of the femoral component. A three-dimensional computational model of the lower limb during deep flexion was created using Kane’s method of dynamics. A hybrid approach was used to determine the boundary conditions of the model. The motions of a total knee arthroplasty patient were measured using fluoroscopy. The motions of the patient were varied from the normal motions to simulate malalignment of the femoral component. The change in forces with malalignments of up to 10° valgus, 10° varus, 10° internal rotation, and 10° internal rotation were determined. An increase in the axial tibiofemoral contact force from 2.44 times body weight (BW) to 2.62 BW and a decrease in the quadriceps force from 6.8 to 5.65 BW were observed with varus malalignment. The medial-lateral patellofemoral contact force decreased from 0.95 BW to 0.1 BW with 10° varus positioning of the femur and increased to 2.2 BW with 10° valgus positioning of the femur and a decrease in the patellar ligament forces from 1.70 to 1.63 BW was observed. Changes in the tibiofemoral and patellofemoral forces of 1–2 BW were observed as the femur was malaligned with respect to the tibia. The most significant of these changes was the medial-lateral patellofemoral contact force. The implications of these findings are that malalignment could result in increased patellar subluxation or increased wear of the polyethylene component. Concerns were raised that this initial subject evaluated may not have had optimum alignment, thus leading to more optimal bearing surface stress conditions with varus malalignment. Future studies will be evaluated for subjects having the joint line restored to conditions for non-implanted knees.
The objective was to assess and compare polyethylene-bearing mobility patterns and magnitudes in various total knee arthroplasty(TKA) types of mobile bearing TKA. In vivo kinematics were determined for 38 subjects implanted with either a PCL-retaining (PCR) mobile bearing TKA, which allows both rotation and antero-posterior (AP) translation (n=20), aposterior stabilized rotating platform (PS) TKA (n=9) or a PCL-sacrificing (PCS) rotating platform TKA (n=9) using video fluoroscopy. Using a 3D model-fitting technique, kinematics were determined during a weight-bearing deep knee bend. The femoral and tibial components and mobile bearing polyethylene insert (implanted with four tantalum beads) were overlaid onto the fluoroscopic images to determine bearing mobility. AP bearing translation was determined for subjects implanted with a PCR mobile bearing TKA. Subjects implanted with PCR and PCS TKA were evaluated at a single interval. Those with a PS TKA were evaluated at two postoperative intervals, (12 months apart) to assess changes in bearing mobility over time. All subjects experienced polyethylene bearing rotation relative to the tibial tray and minimal rotation relative to the femoral component. The average maximum amount of bearing rotation was 10.3o (3.0o to 20.8o), 8.9o (5.3o to 14.1o), and 8.5o (3.3o to 12.9o) for subjects implanted with a PCR, PS, and PCS mobile bearing TKA, respectively. For subjects implanted with a PS mobile bearing TKA, bearing mobility increased to 9.8o (4.8o to 14.1o) one year later post-operatively. All subject shaving a PCR mobile bearing TKA experienced AP bearing translation, averaging 5.6 mm (1.0 mm to 12.5 mm). These results demonstrate that the polyethylene bearing is rotating and translating relative to the tibial tray in all subjects. Minimal motion occurred between the femoral component and the polyethylene insert. Magnitude and direction of bearing motion varied among subjects. Paradoxical anterior translation of the bearing during deep flexion was observed in the PCR TKA group. The presence of bearing mobility should result in lower contact stresses, reducing the potential for polyethylene wear.
We carried out weight-bearing video radiological studies on 40 patients with a total knee arthroplasty (TKA), to determine the presence and magnitude of femoral condylar lift-off. Half (20) had posterior-cruciate-retaining (PCR) and half (20) posterior-cruciate-substituting (PS) prostheses. The selected patients had successful arthroplasties with no pain or instability. Each carried out successive weight-bearing knee bends to maximum flexion, and the radiological video tapes were analysed using an interactive model-fitting technique. Femoral lift-off was seen at some increment of knee flexion in 75% of patients (PCR TKA 70%; PS TKA 80%). The mean values for lift-off were 1.2 mm with a PCR TKA and 1.4 mm with a PS TKA. Lift-off occurred mostly laterally with the PCR TKA, and both medially and laterally with the PS TKA. Separation between the femoral condyles and the articular surface of the tibia was recorded at 0°, 30°, 60° and 90° of flexion. Femoral condylar lift-off may contribute to eccentric polyethylene wear, particularly in designs of TKA which have flatter condyles. Coronal conformity is an important consideration in the design of a TKA.
