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CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number 403, pp. 161167


2002 Lippincott Williams & Wilkins, Inc.

Joint Proprioception Before and After


Total Knee Arthroplasty
Makoto Wada, MD*; Hideo Kawahara, MD*;
Seiichiro Shimada, RPT*; Tsuyoshi Miyazaki, MD**;
and Hisatoshi Baba, MD**

To investigate the effects of total knee arthroplasty on joint proprioception, the absolute angular error of the knee in 38 consecutive patients before and after total knee arthroplasty
for osteoarthritis and in 23 age-matched control
subjects were examined. Varus and valgus laxity of the knee and muscle strengths of the thigh
were measured using appropriate instruments.
There were no signicant differences in absolute
angular error before and after total knee arthroplasty, independent of retaining or substituting
the posterior cruciate ligament. The absolute
angular error of the knee with a normal appearing anterior cruciate ligament was larger
than that with a missing anterior cruciate ligament before total knee arthroplasty and decreased signicantly after surgery. The absolute
angular error correlated with the varus and
valgus laxity of the knee, but did not correlate
with the strength of thigh muscles after total
knee arthroplasty. These results suggest that deciency of the anterior cruciate ligament may
not adversely affect proprioception in severe

knee osteoarthritis. In addition, proper ligament balance may partly contribute to better
proprioception after total knee arthroplasty.

Proprioception serves to protect joints against


injurious movement and it is critical to the maintenance of joint stability under dynamic conditions.14 The breakdown of such a protective and
stabilizing mechanism may initiate or contribute
to degenerative changes in the joints.22
A decline in position sense after total knee
arthroplasty also is considered to be important
because it may be a signicant risk factor in
failure of total knee arthroplasty.20 Although
some studies have examined proprioception after total knee arthroplasty, the effect of knee
replacement is controversial. Some groups reported that the replaced knee had better proprioception than knees with osteoarthritis,1,4,24
whereas others reported no differences between
replaced and unreplaced knees3,11,20 or worsening in proprioception after total knee arthroplasty than in the contralateral side.5 To the authors knowledge, all previous studies, with the
exception of that by Atteld et al,1 compared
the results only after total knee arthroplasty. In
addition, previous studies have compared the
effect of retention and that of substitution of the
posterior cruciate ligament on proprioception
only postoperatively.5,11,13,18,24 Such compar-

From the *Division of Rehabilitation Medicine and the


**Department of Orthopaedic Surgery, Fukui Medical
University, Fukui, Japan.
Reprint requests to M. Wada, MD, Fukui Medical University, Shimoaizuki 23, Matsuoka-cho, Yoshida-gun,
Fukui 9101193, Japan.
Received: May 16, 2001.
Revised: December 11, 2001.
Accepted: January 22, 2002.
DOI: 10.1097/01.blo.0000022176.66847.9b

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Wada et al

isons do not show the effect of knee replacement


exactly; therefore, comparisons before and after
surgery in the same patients are needed.15
In subjects without osteoarthritis of the knee,
proprioceptive performance of the knee depends on the presence or absence of the anterior
cruciate ligament.6 In severe osteoarthritis of
the knee, various degenerative changes are seen
in the anterior cruciate ligament,23 but the effect
of the changes in anterior cruciate ligament on
knee proprioception has not been investigated.
The anterior cruciate ligament is sacriced routinely for knee replacement, but it is not known
whether this procedure improves or worsens
knee proprioception.
Recent study after total knee arthroplasty
has suggested that intraarticular components
do not inuence knee proprioception.11 However, whether extracapsular structures, such as
collateral ligaments or muscles, around the
knee have any signicant effects on position
sense of the replaced knee are unknown. The
static function of the collateral ligaments can
be evaluated quantitatively by varus and valgus laxity of the knee. Reduction in muscle activation can cause loss of muscle strength that
supports the knee and may lead to instability
of the knee.7 The purpose of the current study
was to compare knee proprioception in consecutive patients before and after total knee
arthroplasty. In addition, the effect of morphologic changes in the anterior cruciate ligament on proprioception was evaluated. Furthermore, the authors examined whether there
were any relationships between proprioceptive
performance and varus and valgus joint laxity
or isokinetic muscle strengths of the knee.
MATERIALS AND METHODS
Subjects
Thirty-eight patients with medial compartment knee
osteoarthritis who were scheduled for total knee
arthroplasty were examined. There were three men
and 35 women with an average age of 72.6 years
(range, 5880 years). All subjects had bilateral knee
extension decits less than 20 and exion more
than 90, before and after total knee arthroplasty.

Clinical Orthopaedics
and Related Research

All patients required soft tissue releases including


the medial collateral ligament, pes anserinus tendons, posteromedial capsule, and resection of the
posterior cruciate ligament sometimes was necessary. Twenty of the patients received a posterior
cruciate ligament retaining prosthesis (Deltat, Osteonics, Allendale, NJ) whereas the other 18 patients received a posterior cruciate ligament substituting prosthesis (Scorpio PS, Stryker, Allendale,
NJ). The patella was resurfaced in all patients. Subjects with neurologic disorders, musculoskeletal
diseases other than knee osteoarthritis, vestibular
diseases, metabolic diseases, or previous injury or
surgery to the lower extremity were excluded from
the study. Another group of 23 age-matched subjects were selected as the control group. The group
included two men and 21 women with an average
age of 71.5 years (range, 6076 years).
For the patients, proprioception, varus and valgus laxity, and isokinetic muscle strengths of the
knee were measured before and 12 to 25 months
(average, 18 months) after total knee arthroplasty.
In addition, mechanical axis (hip-knee-ankle angle) was measured on radiographs taken preoperatively with the patient weightbearing. For the control subjects, measurements of proprioception, varus
and valgus laxity, and isokinetic muscle strengths
of the knee also were made. The study protocol was
approved by the ethics committee of Fukui Medical
University and all subjects gave written informed
consent before the study.

Measurement of Knee Proprioception


Knee proprioception was measured by the method
in which the subject actively set the initial and repeat angles, a modied procedure by Lattanzio et
al.13 An electrogoniometer of the Genucom knee
analysis system (Faro Medical Technologies, Montreal, Quebec, Canada) was used to measure angular joint motion, which had six-degrees-of-freedom
regardless of axial rotation of the shank with respect to the thigh. The subject sat on the Genucom
table wearing eye masks and with his or her legs
hanging freely over the side of the table. An electrogoniometer was placed across the knee with rm
belts. The starting position was approximately 90
knee exion and the testing range was 30 to 50
knee exion (Fig 1). Six randomized test angles
were evaluated in each experimental trial. Only the
replaced knee was evaluated in all patients. The
subject was asked to extend the testing leg from the
starting position to a predetermined angle (3050

Number 403
October, 2002

Proprioception in Total Knee Arthroplasty

163

reported previously.22 The reproducibility of measurement of the varus and valgus laxity was calculated in ve patients with knee osteoarthritis and
the average coefcient of variation was 8%.

Measurement of Isokinetic
Thigh Muscle Strength

Fig 1. An examiner checked the knee angle


through the monitor of the Genucom Knee Analysis System as the subject extended the knee to
the predetermined angle.

knee exion). When the test angle was reached, the


subject was asked to hold the position for 3 seconds
and then return the leg to the starting position. After a 5-second interval, the subject was asked to reproduce the test angle and acknowledge, through
verbal cues, when the subject thought he or she had
reproduced the designated test angle within 5 seconds. Each test trial was conducted six times after
a 1-minute rest. The mean absolute angular error,
the absolute difference between the actual and the
subjects perceived test angle, of the six trials was
designated as proprioceptive performance.

Reliability Test of Knee Proprioception


To assess the reliability of the aforementioned proprioception test protocol, 10 patients with knee
osteoarthritis had repeated measurements 1 week
apart. The reliability was evaluated using one-way
analysis of variance (ANOVA) and measurement
of intraclass coefcient. The intraclass coefcient
of the 1 week trial was 0.90.

Measurement of Varus and


Valgus Laxity of the Knee
Varus and valgus laxity of the knee was measured
by instrumented measurement, using the Genucom
Knee Analysis System (Faro Medical Technologies Inc). The average of three trials of total varus
and valgus rotation of the tibia with respect to femur was expressed when 8 N-m force was applied
to the tibia in 20 knee exion. The test was evaluated according to the modied Genucom protocol

Isokinetic thigh muscle strength was measured in


the more symptomatic lower extremity using an isokinetic dynamometer (Cybex II, Cybex Medical,
Ronkonkoma, NY) with an angular velocity of 30
per second. Five trials were done on each leg and the
average of the peak values of extension and exion
was expressed per body weight. To assess reliability, 10 patients with knee osteoarthritis had repeated
measurements 1 week after the study. Reliability of
muscle strength measurement was determined by
ANOVA with repeated measures and intraclass coefcients. The coefcients were 0.90 for peak extensor and 0.93 for peak exor muscle strength.

Statistical Analysis
All data were analyzed with StatView 5.0 software
(Abacus Concepts, Berkeley, CA). Preoperative
and postoperative data of each patient group were
compared using a paired t test. Data of the entire
patient group and the control group were compared
using the unpaired t test. The relationship between
the absolute angular error and each parameter was
examined by Spearman signed rank test. A value of
0.05 was considered statistically signicant.

RESULTS
Preoperatively, the mean absolute angular error of all patients was 4.4 (standard deviation,
2.4) and changed to 3.6 (standard deviation,
1.9) after total knee arthroplasty (p  0.07).
The average absolute angular error of the control group was 2.4 (standard deviation, 1.1),
which was signicantly smaller than the aforementioned values (p  0.01). Average absolute angular error of the group with posterior
cruciate ligament retaining knee replacement
was similar to that in patients with the posterior cruciate ligament substituting knee replacement before and after total knee arthroplasty (Table 1).
Macroscopic changes of the anterior cruciate
ligament were classied into three categories

164

Clinical Orthopaedics
and Related Research

Wada et al

TABLE 1. Absolute Angular Error of the Replaced Knees with Posterior Cruciate
Ligament Retaining and Posterior Cruciate Ligament Substituting Prostheses
Type of Prostheses
Posterior cruciate ligament retaining (n  20)
Posterior cruciate ligament substituting (n  18)

Before Total Knee


Arthroplasty

After Total Knee


Arthroplasty

4.4 (2.5)
4.3 (2.4)

3.5 (2.0)
3.6 (2.0)

Values are expressed as mean and (standard deviation).


There were no signicant differences among any of the variables.

at total knee arthroplasty; normal-appearing,


partially ruptured or lax, and missing.23 Preoperatively, the absolute angular error of the
group with normal-appearing anterior cruciate
ligaments was higher than in subjects with a
missing anterior cruciate ligament (p  0.05).
There were no signicant differences among the
three groups postoperatively. The absolute angular error of the knees with normal-appearing
anterior cruciate ligaments diminished significantly (p  0.05), whereas the absolute angular error of the knees with lax or missing anterior cruciate ligaments changed little after total
knee arthroplasty (Table 2).
The average varus and valgus laxity of the
knee was 15 (standard deviation, 7.9) preoperatively, which was signicantly larger (p 
0.01) than that of the controls (average, 12;
standard deviation, 4.0). After total knee
arthroplasty, it signicantly (p  0.01) decreased to an average of 10 (standard deviation, 3.7), which was within the normal level
(Fig 2). Preoperatively, the average peak extensor muscle strength and peak exor muscle

strength were 0.42 N-m/kg (standard deviation, 0.17 N-m/kg) and 0.33 N-m/kg (standard
deviation, 0.12 N-m/kg), respectively. They
increased signicantly (p  0.01) after total
knee arthroplasty (average, 0.78 N-m/kg; standard deviation, 0.18, 0.51 and 0.15 N-m/kg, respectively). However, both measurements after total knee arthroplasty were signicantly (p
 0.05) smaller than the control (average, 1.06
N-m/kg; standard deviation, 0.38, 0.66 and
0.22 N-m/kg, respectively) (Fig 3).
The relationship between absolute angular
error and varus and valgus laxity, peak extensor
or exor muscle strength, hamstring to quadriceps strength ratio, and mechanical axis also
were examined before and after total knee
arthroplasty. There was no relationship between the absolute angular error and any of
these variables. Postoperatively, the absolute
angular error signicantly (p  0.01) correlated
with varus and valgus laxity, but the correlation
was relatively weak (Rs  0.50). Neither muscle strength or hamstring to quadriceps strength
ratio correlated with the absolute angular error.

TABLE 2. Absolute Angular Error of the Three Groups According to Morphologic


Changes of the Anterior Cruciate Ligament
Morphologic Changes in
Anterior Cruciate Ligament
Normal appearing (n  10)
Lax (n  17)
Missing (n  11)
All (n  38)
Values are expressed as mean and (standard deviation).
*p  0.05

Before Total Knee


Arthroplasty

After Total Knee


Arthroplasty

5.1 (2.6)*
4.6 (2.6)
2.9 (1.3)
4.4 (2.4)

3.7 (2.1)*
4.0 (2.2)
2.5 (0.8)
3.6 (1.9)

Number 403
October, 2002

Fig 2. Varus and valgus laxity of the knee (total


varus and valgus angulation) signicantly decreased to the control level after total knee arthroplasty. *Statistically signicant (p  0.05)

DISCUSSION
Intraarticular structures, such as cruciate ligaments and menisci, are responsible for proprioception in the normal knee, whereas mechanoreceptors in severe osteoarthritic knees are
signicantly small in number and are much
less functional compared with those of the
normal knees.8,16 Therefore, these structures
are unlikely to contribute to improved proprio-

Proprioception in Total Knee Arthroplasty

165

ceptive performance of the knee with severe


osteoarthritis. The results of the current study
showed that the preoperative absolute angular
error of the knees with missing anterior cruciate ligaments tended to be smaller than those
with normal-appearing anterior cruciate ligaments. The absolute angular error of the knees
with normal-appearing anterior cruciate ligaments decreased signicantly, whereas the absolute angular error of the knees with missing
anterior cruciate ligaments changed little after
total knee arthroplasty. This apparent contradictory result means that deciency of the anterior cruciate ligament in severe osteoarthritis might not adversely affect proprioceptive
performance. Weiler et al25 proposed that joint
receptors of the osteoarthritic knees even may
have an adverse effect on the maximal proprioceptive performance. Previous studies have
shown that patients with knee osteoarthritis
have reduced sensory input (loss of sensory information) compared with healthy subjects.14,17
It also has been reported that this loss of sensory information leads to somatosensory cortical reorganization.12 Moreover, abnormalities
in somatosensory evoked potentials correlate
signicantly with the reduction in position
sense of the knee in patients with a decient
anterior cruciate ligament.22 In severe knee osteoarthritis, patients with a missing anterior
cruciate ligament may show a more profound

Fig 3. Isokinetic extensor and exor muscles of the knee (peak torques) increased signicantly after
total knee arthroplasty, but did not reach the control level.

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Wada et al

loss of sensory information compared with patients with an apparently normal anterior cruciate ligament. Accordingly, more extensive cortical reorganization may occur in patients lacking
the anterior cruciate ligament, which results in
less reduction in proprioception. The sample
size of the different patient subgroups in the
current study was relatively small and therefore
meaningful statistical comparisons among subgroups could not be made. However, data of the
entire group showed that the absolute angular
error tended to improve after total knee arthroplasty in the current study, although this change
was not statistically signicant.
Simmons et al19 reported the lack of differences in the proprioception among replaced
knees with anterior cruciate ligament and posterior cruciate ligament (unicondylar design),
with posterior cruciate ligament (posterior
cruciate ligament-retaining design), and without both cruciate ligaments (posterior cruciate
ligament-sacrificing design). Other authors
have reported that proprioception in knees with
posterior cruciate ligament-retaining prostheses is almost identical to that in knees with
posterior cruciate ligament-substituting prostheses.5,11,13,18 Studies from the current authors
laboratory designed to examine knees with posterior cruciate ligament-retaining and posterior
cruciate ligament-substituting designs before
and after total knee arthroplasty showed that the
use of either design resulted in almost similar
proprioceptive changes. The post and cam engages at an angle greater than 60 exion in the
Scorpio posterior stabilized knee prosthesis and
it does not function in less than this angle range.
Therefore, it may not be appropriate to compare
the posterior cruciate retaining and the posterior
stabilizing design at this test angle (approximately 40). However, the former group used a
condylar design with a preserved posterior cruciate ligament and the latter group used a posterior stabilizing design after sacrice of the
posterior cruciate ligament. Accordingly, the
current study compared the groups between
preservation and sacrice of the posterior cruciate ligament rather than groups using a condylar
design insert and posterior stabilizing insert.

Clinical Orthopaedics
and Related Research

It is known that joint laxity may have adverse effects on proprioception in healthy subjects2 and patients with specic neuropathies.9
However, little is known about the relationship
between joint laxity and proprioception in
knees with osteoarthritis. Pai et al14 did not nd
a signicant correlation between varus and valgus laxity and proprioception in patients with
osteoarthritis of the knee. This suggests that
mechanoreceptors located in the collateral ligaments contribute little to proprioception in the
osteoarthritic joint.14 The current preoperative
results were similar to those of Pai et al. However, Atteld et al1 showed that soft tissue balance in exion and extension at total knee
arthroplasty was important to allow satisfactory
postoperative proprioception of the knee. These
results indicate that extracapsular structures
such as the collateral ligaments play an important role in proprioception. A signicant correlation also was found between joint proprioception and varus and valgus laxity after total
knee arthroplasty. The current results suggest
that mechanoreceptors in and around the collateral ligaments probably have little, if any, function in poorly balanced knees with osteoarthritis. However, after restoration of the ligament
balance to near normal, mechanoreceptor function might be restored in proportion to the varus
and valgus laxity after total knee arthroplasty.
The extensor muscle of the knee is considered to be one of the structures that stabilizes
the knee.21 It also is known that the muscle
spindle is one of the major receptors that imparts proprioceptive information.26 Hurley et
al10 reported that elderly subjects had less
quadriceps muscle strength and a higher error
of reproduction of joint position sense compared with young or middle-aged subjects,
but found no correlation between quadriceps
strength and knee proprioception. Corrigan et
al6 showed signicant correlation between
hamstring to quadriceps ratio and proprioceptive acuity in anterior cruciate ligament
decient knees, suggesting greater hamstring
dominance was associated with better proprioceptive performance. In the current study, extensor and exor muscle strengths were sig-

Number 403
October, 2002

nicantly increased after total knee arthroplasty but still did not reach normal levels. The
absolute angular error did not correlate with
extensor or exor muscle strength and hamstring to quadriceps strength ratio before and
after total knee arthroplasty. Additional specic evaluations of the muscle function may
be necessary to examine the effect of muscle
function on proprioception of the knee.
The current study showed that knee proprioception did not change signicantly in patients who received total knee arthroplasty, irrespective of retention or substitution of the
posterior cruciate ligament. Intraarticular components, such as the anterior cruciate ligament
may adversely affect proprioception in severe
osteoarthritis. In addition, proper ligament balance may partly contribute to joint proprioception after total knee arthroplasty. Additional
studies are necessary to determine the factors
that can improve proprioception to prevent
joint damage after total knee arthroplasty.
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Proprioception in Total Knee Arthroplasty

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