Impact of surgical alignment, tray material, PCL condition, and patient anatomy on tibial strains after TKA

•Physiological femoral-insert contact conditions and ligament forces were considered.•Tibial anatomy was found to have the largest impact on post-operative bone strains.•The impact of tray material modification was much smaller than the other factors.•Maximizing post-operative fixation is possible using optimized surgical parameters. Bone remodeling after total knee arthroplasty is regulated by the changes in strain energy density (SED), however, the critical parameters influencing post-operative SED distributions are not fully understood. This study aimed to investigate the impact of surgical alignment, tray material properties, posterior cruciate ligament (PCL) balance, tray posterior slope, and patient anatomy on SED distributions in the proximal tibia. Finite element models of two tibiae (different anatomy) with configurations of two implant materials, two surgical alignments, two posterior slopes, and two PCL conditions were developed. The models were tested under the peak loading conditions during gait, deep knee bending, and stair descent. For each configuration, the contact forces and locations and soft-tissue loads of interest were taken into consideration. SED in the proximal tibia was predicted and the changes in strain distributions were compared for each of the factors studied. Tibial anatomy had the most impact on the proximal bone SED distributions, followed by PCL balancing, surgical alignment, and posterior slope. In addition, the thickness of the remaining cortical wall after implantation was also a significant consideration when evaluating tibial anatomy. The resulting SED changes for alignment, posterior slope, and PCL factors were mainly due to the differences in joint and soft-tissue loading conditions. A lower modulus tray material did result in changes in the post-operative strain state, however, these were almost negligible compared to that seen for the other factors.