Kinematic Alignment in Total Knee Arthroplasty Reduces Polyethylene Contact Pressure by Increasing the Contact Area, When Compared to Mechanical Alignment-A Finite Element Analysis

Unrestricted Kinematic alignment (KA) in total knee arthroplasty (TKA) replicates the joint line of each patient by adjusting the cuts based on the anatomy of the patient. Mechanical alignment (MA) aims to restore a neutral mechanical axis of the leg, irrespective of the joint line orientation. The purpose of the present study was to compare contact pressure and contact areas of the polyethylene (PE) bearing surface as well as von Mises stress of the PE-tibial tray interface for MA and KA in the same patient, using CT data and finite element analysis. Finite element models were created from lower leg CT scans of 10 patients with knee osteoarthritis with different phenotypes. Mechanical PE properties were experimentally determined by tensile tests on dumbbell specimens. For numerical simulation purposes an adjusted non-linear material model with the maximum load to failure of 30.5 MPa, was calibrated and utilized. Contact pressure points were the deepest parts of the polyethylene inlay. Contact pressures were either very similar or were increased for MA knees throughout the gait cycle. KA either increased or had a comparable contact area, compared to MA. KA and MA produced comparable von Mises stresses, although both alignments breached the failure point of 30.5 MPa in all 3 valgus knees. This might indicate a higher probability of failure at the inlay-tibial baseplate interface. By maintaining the joint line orientation, KA reduces or has comparable contact pressures on the PE bearing surface by increasing or maintaining the contact area throughout one gait cycle in a validated finite element analysis model in 10 different knee phenotypes. The von Mises stress on the PE-tibial component interface was comparable, except for the valgus knees, where the load to failure was achieved in both alignment strategies and slightly higher stresses were observed for KA. Further studies for different knee phenotypes are needed to better understand the pressure changes depending on the alignment strategy applied.