Excessive flexed position of the femoral component causes abnormal kinematics and joint contact/ ligament forces in total knee arthroplasty

Poor clinical outcomes are reported in excessive flexion of the femoral component in total knee arthroplasty (TKA), but their mechanisms have not yet been elucidated. This study aimed to investigate the biomechanical effect of flexion of the femoral component. Cruciate-substituting (CS) and posterior-stabilised (PS) TKA were reproduced in a computer simulation. The femoral component was then flexed from 0° to 10° with anterior reference, keeping the implant size and the extension gap. Knee kinematics, joint contact, and ligament forces were evaluated in deep-knee-bend activity. When the femoral component was flexed 10° in CS TKA, paradoxical anterior translation of the medial compartment was observed at mid-flexion. The PS implant was best stabilised with a 4° flexion model in mid-flexion range. The medial compartment contact force and the medial collateral ligament (MCL) force increased with the flexion of the implant. There were no remarkable changes in the patellofemoral contact force or quadriceps in either implant. In conclusions, excessive flexion of the femoral component yielded abnormal kinematics and contact/ligament forces. Avoiding excessive flexion and maintaining mild flexion of the femoral component would provide better kinematics and biomechanical effects in CS and PS TKA.