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Advantages of Kinematically Aligned Total Knee Arthroplasty: A Biomechanical Perspective

Overview The fundamental principle of calipered kinematically aligned total knee arthroplasty (KA TKA) is to reproduce the flexion-extension axis of the prearthritic knee and to maintain the original collateral ligament balance and joint line with controlled, symmetric bony resection. A growing number of articles suggest that modification of the conventional neutral mechanical alignment (MA) strategy toward a more native kinematic alignment (KA) strategy with preservation of…

Strategies for Improving the Prosthetic Trochlea Design Based on Differences in Trochlea Morphology Between Femoral Components Set in Kinematic and Mechanical Alignment and the Native Knee

Overview This chapter reviews differences between the morphology of the prosthetic trochlea for four different femoral components set in kinematic alignment (KA) and the native knee in the same femur-cartilage model. Trochlear morphology is described along the arc length of the native trochlea by the medial-lateral location of the trochlear groove, the radial distance of the trochlear groove from the flexion-extension (F-E) axis of the tibiofemoral…

Strategies for Improving Implant Design Based on Differences in Tibiofemoral Kinematics of a Low-Conforming Total Knee Arthroplasty Implanted With Calipered Kinematic Alignment and the Native Knee

Overview This chapter reviews in vitro and in vivo differences in tibiofemoral kinematics between a low-conforming total knee arthroplasty (TKA) implanted with calipered kinematic alignment (KA) and the native knee. Kinematics are defined by laxities and resting positions of the tibia with respect to the femur, and the anterior-posterior (A-P) movements of the femoral condyles with respect to the tibia. Laxities are the translations and rotations…

Kinematic Alignment With Image-Based Robotic Instrumentation

Overview Robotic assistance was recently reintroduced in total knee arthroplasty (TKA) to improve surgical precision and to minimize errors. However, the technique stills focuses on mechanical alignment (MA) philosophies, with minor adaptations. This chapter is meant to highlight the surgical technique of robotic assistance and its suitability for achieving true kinematic alignment (KA) in TKA and discusses its potential benefits over conventional or other computer-assisted techniques.…

Calipered Kinematic Alignment With Navigation Instrumentation

Introduction Computer-assisted surgery (CAS) or navigation has for the best part of two decades been the gold standard for accuracy and precision in total knee arthroplasty (TKA) in terms of creating neutral coronal and sagittal limb alignment. Accuracy refers to how close a measurement is to a “true” value, whereas precision refers to how close a series of measurements are to each other. In terms of…

Calipered Kinematic Alignment Using Patient-Specific Instrumentation

Overview This chapter reviews the history of patient-specific instrumentation (PSI) and then outlines the design rationale, surgical techniques, and results seen in kinematically aligned (KA) total knee arthroplasty (TKA). The goals of KA TKA are to (1) restore the native femoral and tibial articular surfaces, (2) restore the native knee and limb alignment, and (3) reestablish the native tibial compartment forces and laxities of the knee.…

Calipered Kinematic Alignment Total Knee Arthroplasty Performed With Specific Manual Instrumentation, Verification Checks, and a Decision Tree

Overview This chapter contains discussion and video links that assist the surgeon in performing calipered kinematically aligned (KA) total knee arthroplasty (TKA) with specific manual instruments, a verification worksheet, and a decision tree. The treatment of 4726 primary TKAs performed from 2009 through 2019 with KA to restore the patient’s prearthritic joint lines regardless of knee deformity and without ligament release, by the senior author, provide…

Preoperative Evaluation of the Patient for Treatment With a Calipered Kinematically Aligned Total Knee Arthroplasty

Overview With calipered kinematic alignment (KA) technique, preoperative management and evaluation of the arthritic knee patient does not vary vastly from the standard evaluation. However, there are some subtle differences that can aid the surgeon in planning and discussing the surgery with patients. This chapter introduces how to assess the patient in the office in terms of history, physical exam, and the recommended radiographs. This chapter…

It Is Time to Consider a Philosophical Change From Mechanical to Kinematic Alignment

Overview This chapter discusses the research that is driving the change in philosophy from mechanical alignment (MA) to kinematic alignment (KA) in total knee arthroplasty (TKA). The first section discusses the association between MA and patient dissatisfaction after TKA, and how improving satisfaction requires a change in alignment philosophy to one that does not require ligament release. The second section describes the recent discovery of three…

Phenotypes of the Knee and Limb: Rationale for Transitioning Toward Personalized Alignment in Total Knee Arthroplasty

Overview For a long time, the alignment goal for total knee arthroplasty (TKA) was a neutrally aligned limb with orthogonal joint lines to the mechanical axes (mechanical alignment [MA]). This had mainly to do with the belief of a better long-term durability because of more equal load distribution in mechanically aligned TKA. Recognizing the variability in individual knee alignment and compromised functional outcomes in TKA, there…

Orthotic Treatment Considerations for Arthritis and Overuse Syndromes in the Upper Limb

Key Points Many health care professionals commonly see patients with some form of arthritis, especially rheumatoid arthritis (RA) and osteoarthritis (OA). RA and OA can be highly disabling conditions that can affect many aspects of a person's life (e.g., physically, psychologically, socially, economically). The severity of RA and OA can range from mild to severely disabling. Osteoarthritis is a heterogeneous condition in which biomaterial properties of…

Orthoses for the Burned Hand

Key Points Burn injuries involving the hand commonly result in contracture deformity. Deep burns can result in more than just an unacceptable appearance; these patients also experience profound functional consequences for the burned hand, such as loss of fingertips, mutilated nails, joint limitation, and painful scars. Splints are important in the management of a burned hand, and the type of splint used depends on the location…

Upper Limb Orthoses for Persons With Spinal Cord Injuries and Brachial Plexus Injuries

Key Points The goals of upper limb intervention for persons with a spinal cord injury (SCI) include increased independence, prevention of secondary complications, and increased ease and efficiency of activity. Anticipatory rehabilitation refers to rehabilitation that anticipates future treatments and technologies, preventing secondary deformities, and avoiding irreversible treatments that will interfere with future interventions. Orthoses for the upper limb remain a mainstay of SCI rehabilitation. Low-cost,…

Upper Limb Orthoses for the Stroke- and Brain-Injured Patient

Key Points Stroke and brain injury are often complicated by the development of upper motor neuron syndrome. Most spontaneous motor recovery occurs within 6 months of stroke and traumatic brain injury. Combining the therapeutic interventions of oral antispasmodics, therapy, casting, bracing, and targeted chemodenervation is a first-line measure. Definitive surgical procedures to reduce spasticity are effective and include neurectomies, tendon releases, and transfers. It is important…

Principles and Components of Upper Limb Orthoses

Key Points Upper limb orthotics is a challenging and dynamic segment of orthotic practice because of the complexity of coordinated movements of the arm and the hand. Devices are tailored to the individual's functional need, and customized devices are often recommended to appropriately contour to the limb and provide the desired function. Upper limb anatomy and biomechanics differ significantly from other segments of the body, having…

Biomechanics of the Upper Limb

Key Points Achieving a functional range of motion, rather than a normal range of motion, can be an acceptable goal. This functional range of motion, however, can be represented as an overall average or as task specific. At its most fundamental level, a functional hand requires a stable platform of the wrist and forearm and at least two sensate digits with opposable power. Synergistic motion between…

Orthoses for Osteoporosis

Key Points Osteoporosis is a disease characterized by low bone mass and deterioration of the quality of bone tissue, which can lead to an increased risk for fractures. Prevention of vertebral compression fractures (VCFs) is an important consideration in patients with osteoporosis. The consequences of VCFs include acute or chronic back pain, functional limitations, respiratory symptoms, and mood impairment. Comprehensive clinical care for patients with one…

Orthoses for Spinal Trauma and Postoperative Care

Key Points The treatment team must define traumatic fractures as stable vs. unstable. With the exception of upper cervical spine fractures, only stable spine fractures can be considered for orthotic treatment. The primary goal of orthotic interventions is to increase spinal stability in all three anatomical planes by immobilization. Orthotic immobilization may assist with healing and limit progression of a spinal deformity. An understanding of the…

Orthoses for Spinal Deformities

Key Points The use of orthoses for treatment of spinal deformities remains controversial. The natural history of the various disorders for which orthoses are prescribed is still unclear, which limits concrete recommendations for orthotic use. The weight of the literature supports the value of orthotic treatment for various forms of spinal deformity. The use of orthoses in the treatment of spinal deformity is controversial. Most often,…