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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 10  |  Page : 1423-1429

The morphology of proximal tibia geometry amongst the Igbos of South East Nigeria and its implication in total knee replacement


Department of Anatomy, University of Nigeria, Enugu Campus, Enugu, Nigeria

Date of Acceptance16-Aug-2019
Date of Web Publication14-Oct-2019

Correspondence Address:
Dr. E Esom
Department of Anatomy, University of Nigeria, Enugu Campus, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_93_19

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   Abstract 


Background: The morphological parameters of the proximal tibia play a major role in total knee replacement and there are ethnic and gender variations to these parameters. Aim: To evaluate parameters of the proximal tibia geometry amongst the Igbos of South Eastern Nigeria and discuss the clinical implications in total knee replacement. Methods: The proximal tibia parameters of 558 adult tibiae bones, 300 right-sided and 258 left-sided, collected from the osteological unit of the department of anatomy University of Nigeria Enugu campus were measured using a Venier calipers. Results: The values of the determined parameters are as follows: anterior posterior dimension (APD): 5.50 cm, medial lateral dimension (MLD):7.53 ± 5.56 cm, proximal length (PL): 7.32 ± 0.67 cm, proximal width (PW) CM: 4.10 ± 0.30 cm, medial tibia posterior slope (MTPS):11.36 ± 4.15° and lateral tibia posterior slope (LTPS):5.65 ± 2.72°. The correlation test between these parameters of the proximal tibia shows a strong significant correlation between LPTS and MPTS (r =0.814, P <.001). The comparison of the means of the MPTS of both sides using independent samples t test shows a mean difference that is not significant (p =0.628). A comparison of the values with other populations shows significant mean difference for MLD with that of Chinese and American populations (p <.05). The mean difference between the APD of this study and the Chinese is significant (p =0.007). A comparison of MPTS and LPTS for Malaysian, Chinese, and white Americans shows a significance difference for all the three populations (p <.05). Conclusion: These determined values should be taken into consideration during tibia surface coverage in total knee replacement amongst the Igbo population.

Keywords: Proximal tibia geometry, Igbos, South East Nigeria, total knee replacement


How to cite this article:
Katchy A U, Agu A U, Ikele I T, Esom E, Nto N J. The morphology of proximal tibia geometry amongst the Igbos of South East Nigeria and its implication in total knee replacement. Niger J Clin Pract 2019;22:1423-9

How to cite this URL:
Katchy A U, Agu A U, Ikele I T, Esom E, Nto N J. The morphology of proximal tibia geometry amongst the Igbos of South East Nigeria and its implication in total knee replacement. Niger J Clin Pract [serial online] 2019 [cited 2019 Nov 15];22:1423-9. Available from: http://www.njcponline.com/text.asp?2019/22/10/1423/269027




   Introduction Top


The knee joint is a modified hinge joint which has two articulations, namely the patella femoral and tibia femoral joints. The biomechanics of the knee is controlled by the ligaments and the proximal tibia geometry.[1],[2],[3] The knee joint is prone to injuries and degenerative changes with resultant end stage osteoarthritis (OA), which may result in disability.[4]

One of the remedies of this end stage OA is total knee replacement (TKR) whose outcome depends on proper soft tissue balancing, accurate sagittal and rotational alignment and minimal overhang of the components.[5],[6],[7],[8],[9] The morphological parameters of the proximal tibia play a major role in achieving this, and include the medial posterior slope, lateral posterior slope, proximal tibial length, medial condyle area, and the lateral condyle area.[10],[11]

There are ethnic and gender variations to these parameters and studies have linked this variability with TKR outcomes.[12],[13],[14]

Most of the implants designed being used in TKR are based on parametersof the western population and a lot of implant mismatched incompatibility has been reported in some populations.[15] As a response to these reports, Asian workers [16],[17],[18],[19],[20],[21] have tried to establish values for their own populations. There is no published comprehensive literature, to our knowledge, on these parameters amongst the ethnic Igbos population. The aim of the study therefore is to evaluate parameters of the proximal tibia geometry amongst Igbosof South Eastern Nigeria and compare the determined values with known populations, determine any correlation within these parameters and between these parameters and body laterality, as well as discuss the clinical implications of these findings in total knee replacement.


   Methods Top


558 tibiae bones, 300 right-sided and 258 left-sided, collected from the osteological unit of the department of anatomy University of Nigeria Enugu campus were analyzed. Bones with any pathology (like tumour, fractures, infections, osteoarthritis etc.), bones whose epiphysis have not fused and bones with age long defects were excluded from the study. The proximal tibia parameters were measured in centimeters (cm) using Venier sliding caliper and goniometer devices using the following landmarks:

  1. Anterior-posterior dimension (APD) of the tibia plateau – the distance between the most anterior and posterior margins of the tibia plateau [Figure 1].
  2. Medio-lateral dimensions (MLD) – the distance between the most medial and lateral margins of the tibia plateau [Figure 2].
  3. Proximal tibia length (PTL) – the distance from the tibia plateau to a point 1 cm below the tibial tuberosity [Figure 3]
  4. Proximal tibia width (PTW) – the width measured at a point 1 cm below the tibial tuberosity [Figure 4]-.
  5. Medial-posterior tibia slope (MPTS) – this was measured with a goniometre. It is the angle of the slope of the medial tibia plateau [Figure 5].
  6. Lateral-posterior tibia slope (LPTS) – this was measured with a goniometre. It is the angle of the slope of the lateral tibia plateau [Figure 6].
Figure 1: Measurement of Anterior-Posterior Dimension of the Proximal Tibia

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Figure 2: Measurement of Medio-Lateral Dimension of the Proximal Tibia

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Figure 3: Measurement of Proximal Tibia Length

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Figure 4: Measurement of Proximal Tibia Width

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Figure 5: Measurement of Medial Posterior Tibia Slope Angle

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Figure 6: Measurement of Lateral Posterior Tibia Slope Angle

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Statistical analysis

The IBM SPSS package (IBM Corp., IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY, USA) developed by International Business Machines Corporation (IBM) was used to analyze our data. Descriptive statistics were calculated for all variables of interest and continuous measures were summarized as means and standard deviations. The P values for comparing means of continuous variables were determined after selecting a level of significance (α = 0.05). The one sample t -test for comparison with other populations and independent t-test to compare the means for the determined PTG parameters for laterality. The Pearson correlation coefficient was used to determine correlation between the PTG parameters.


   Results Top


The determined values of the proximal tibia parameters are anterior posterior dimension (APD): 5.50 cm, medial lateral dimension (MLD):7.53 ± 5.56 cm, proximal length (PL): 7.32 ± 0.67 cm, proximal width (PW) CM: 4.10 ± 0.30 cm, medial tibia posterior slope (MTPS):11.36 ± 4.15° and lateral tibia posterior slope (LTPS):5.65 ± 2.72° [Table 1].
Table 1: Determined values of parameters of the proximal tibia

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The correlation test between the parameters of the proximal tibia shows a strong significant correlation between LPTS and MPTS (r =.814, P <.001). There is no correlation between the other parameters [Table 2].
Table 2: Correlations between the parameters of the proximal tibia (n=558)

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The comparison of the means of the MPTS of both sides using independent samples t test shows a mean difference that is not significant (p =.628). The mean differences in the other parameters are significant (p <.05). [Table 3] A comparison of the determined values with other populations [Table 4] shows significant mean difference for MLD with that of Chinese and American populations (p <.05) while that of Korean population did not (p >.05).
Table 3: Comparison of the proximal tibia parameters based on laterality using Independent Samples Test

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Table 4: Comparison of the proximal tibia parameters with that of other populations

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The mean difference between the APD of this study and that of American and Korean is not significant (P =.075 and P =.014) while that of comparison with the Chinese is significant (P =.007).

A comparison of MPTS and LPTS for Malaysian, Chinese, and white Americans shows a significance difference for all the three populations (p <.05). A comparison of means of MPTS and LPTS using a paired sample t test shows a difference that is significance (p <.05). [Table 5]
Table 5 :Comparison of medial and lateral posterior tibia slope using a Paired Samples Test

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   Discussion Top


The purpose of the study was to evaluate parameters of the proximal tibia geometry amongst the Igbos of South Eastern Nigeria and compare the studied parameters withother known populations, determine any correlation within these parameters and between these parameters and body laterality as well as discuss the clinical implications in total knee replacement. These values determined showed a mean difference between the means of MPTSand LPTS. This study supports earlier studies [22],[23],[24],[25],[26] that suggested that the MPTS is greater than that of the LPTSthough it is at variance with the findings of other studies [27],[28],[29], which demonstrated a higher angle of LPTS in patients with anterior cruciate ligament deficiency in female patients. The reason for this difference may be attributed to the difference in choice of materials between real bones and radiological images used for the studies. The findings of Weinberg et al.[30] who worked on osteological materials further confirms this view. An analysis of biomechanics of the knee has shown that an important contributing factor to the stability of the knee is the degree of PTS [1] and a correlation between increased anterior translation of the knee and increased PTS has been demonstrated in cadaver models.[31]

These findings are supported by kinematic evidence confirming that in active gait, larger PTS results in an increased anterior tibial translation and ACL force.[25]

In a non-complex primary total knee replacement, the thickness of resection and angle of posterior slope are taking into consideration while respecting the tibia surface. The knee systems are designed to have both the tibia cutting blocks and tibia external alignment device to achieve these. Most knee systems have 0-5° tibia cutting blocks with a slope adjustment design to achieve an extra slope when desired. They are designed based on 10° slope of the Caucasians with 3° in the block and 7° built in the insert. This significant difference between the native slopes of the whites and that of this study should be taken into consideration when slopes are being recreated in patients of the ethnic Igbo population.

The medial lateral dimensions (MLD) shows a significant difference between our values and that of Chinese [19] and American [32] people, while that anterior posterior dimensions (APD) shows a non-significant difference with that of the American values only. Total knee replacement (TKR) is an operation that requires precision with adequate soft-tissue balancing and resection of bone thickness that is equal to the thickness of the prosthetic component implanted, in order to achieve equal flexion-extension gaps which will ensure the stability of the knee joint throughout the range of motion. The success of this procedure depends on proper selection of prosthesis, accurate sizing and proper placement of the components.

The anteroposterior dimension (APD) of the prosthesis plays an important role in sustaining flexion-extension spacing while the medio-lateral dimension (MLD) ensures satisfactory coverage of the resected bone surface and tension free wound closure.[36] long-term survivorship of these implants depends on maximal implant coverage on the resected bone surface which decreases the stress applied to the bone implant interface, which has been found to be a contributing factor.[37],[38],[39]

There was a significant difference between the MLD of the Chinese and American populations and that of this study while that of the Korean population did not show any significant difference. However, apart from the Chinese population, this study did not demonstrate a corresponding significant difference between the APD of these populations and that of this study. This may be due to the postulations of Zengin et al.[40] who demonstrated in their study that Black men have higher BMD compared to White and South Asian men. These differences they suggested are reflected in the greater bone strength in Black men and South Asian men who had thinner cortices at the radius and tibia. This study suggests that these values should be taken into consideration in assessment of tibia surface coverage during TKR amongst the Igbo population.

There is no correlation with the tibiaparameters the exception being between the LPTS and MPTS which shows a significant correlation. This is in keeping with the findings of Zhang et al.[41]

This study showed a significant difference in the proximal tibia parameters with the exception of the medial tibia slope between the right and left tibia. This is in consonance with the findings of Swati Gandhi et al.[42] The strength of this study is anchored on the fact that these measurements unlike the radiological studies are done on real bones and therefore are more likely to give more accurate measurements. In spite of this, the limitation of this study made it impossible for the authors to take measurements like aspect ratio, analyse the proximal tibia based on age and sex as these facts were not available in the institution's skeletal museum. Considering the fact that these parameters are important in design and surgery of TKR, it is recommended that a cadaver study should be carried out to establish these parameters.


   Conclusion Top


This study has evaluated parameters of the proximal tibia geometry in Igbos of South Eastern Nigeria and compared them with Chinese and American populations, in which the medial lateral dimensions (MLD) shows a significant difference between the values. There is no correlation with the tibia parameters the exception being between the LPTS and MPTS which shows a significant correlation. This study showed a significant difference in the proximal tibia parameters with the exception of the medial tibia slope between the right and left. During tibia surface coverage in TKR amongst the Igbo population, it is recommended that these values should be taken into consideration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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