Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty

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Asian Journal of Surgery xxx (xxxx) xxx

Available online at www.sciencedirect.com

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ORIGINAL ARTICLE

Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty Yong-Gon Koh a,1, Jin-Ah Lee b,1, Heoung-Jae Chun b, Changhyun Baek c, Kyoung-Tak Kang b,* a Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, 06698, Republic of Korea b Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea c Department of Mechanical and Control Engineering, The Cyber University of Korea, 106 Bukchon-ro, Jongnogu, Seoul, 03051, Republic of Korea

Received 15 July 2019; received in revised form 18 September 2019; accepted 26 September 2019

KEYWORDS Carbon fiber; Finite element analysis; Mobile-bearing; Polyether etherketone; Total knee arthroplasty

Summary Background: There is a gradual increase in the number of patients for total knee arthroplasty (TKA), and TKA demonstrates reliable clinical outcomes. The orthopaedic biomaterials community continuously attempted over the past decades to improve the longevity of UHMWPE in TKA by using various improved technologies. Polyetheretherketone (PEEK) and carbon fiber reinforced-PEEK(CFR-PEEK) are suggested as potential tibial insert materials to replace UHMWPE in some applications. The aim of this study involves evaluating the biomechanical effects of UHMWPE and CFR-PEEK tibial materials on mobile-bearing TKA. Methods: The finite element (FE) model was obtained by conducting computed tomography and magnetic resonance imaging. The FE investigation included three types of loading conditions corresponding to the loads used in the experiments for FE model validation and model predictions under deep-knee bend loading conditions. We investigated forces on quadriceps, collateral ligament and patellar tendon with UHMWPE and CCFR-PEEK tibial insert materials under the deep-knee-bend condition. Results: Quadriceps force decreased with flexion for CFR-PEEK when compared to that for UHMWPE. A similar trend was observed in terms of the patellar tendon force. An opposite trend was observed in the collateral ligament. Medial collateral ligament force in the CFR-PEEK

* Corresponding author. Fax: þ82 2 362 2736. E-mail address: [email protected] (K.-T. Kang). 1

Yong-Gon Koh and Jin-Ah Lee contributed equally to this work and should be considered co-first authors.

https://doi.org/10.1016/j.asjsur.2019.09.010 1015-9584/ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010

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Y.-G. Koh et al. exceeded that in the UHMWPE, and lateral collateral ligament force in the UHMWPE exceeded that in the CFR-PEEK. Conclusion: The CFR-PEEK represents an alternative insert material given its superior biomechanical effect after mobile-bearing total knee arthroplasty. However, a balance between the medial and lateral ligaments is considered as an important factor in the CFR-PEEK tibial insert due to its opposite biomechanical effect. ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction There is a gradual increase in the number of patients for total knee arthroplasty (TKA), and TKA demonstrates reliable clinical outcomes.1,2 Specifically, mobile-bearing TKA was developed 30 years ago as an alternative to fixed-bearing TKA to achieve high conformity and low contact stress at the interface between the metallic femoral component and the ultrahighmolecular-weight polyethylene (UHMWPE) tibial insert.3,4 These TKAs are expected to reduce shear forces and polyethylene wear to prevent losses in range of motion. Previous in-vitro studies reported the superiority of mobilebearing TKA over fixed-bearing TKA with respect to the rate of polyethylene wear, contact stress and contact area.4e6 However, a few studies indicated the absence of differences in clinical results between the same in terms of parameters such as range of motion, clinical score, longterm survival and wear.7e9 The most serious biomechanical problem that was observed in mobile-bearing TKA corresponds to wear. The orthopaedic biomaterials community continuously attempted over the past decades to improve the longevity of UHMWPE in TKA by using various improved technologies.10,11 However, an apparent trade-off exists between each of the factors with increases in the cross-linkage that is assumed to enhance wear performance associated with a decrease in fatigue resistance.12,13 The use of an alternative material in the place of UHMWPE could lead to a reduction in wear, and therefore, an increase in joint life expectancy.14 Alternative materials are investigated to improve the survivorship of joints in younger patients. Polyetheretherketone (PEEK) and carbon fiber reinforcedPEEK (CFR-PEEK) are suggested as potential tibial insert materials to replace UHMWPE in some applications.15 Previous studies revealed that CFR-PEEK wear particles did not exhibit cytotoxic effects on the human cells, thereby suggesting that this material can cause little or no adverse tissue reaction.16 Specifically, PEEK was successfully used in a number of medical implantations due to its combination of mechanical strength and biocompatibility.17 However, PEEK does not demonstrate equivalent wear performance relative to hard bearings.18,19 Additionally, Brockett et al recently proved that design parameter is an important factor in TKA by using CFR-PEEK materials.20 They indicated that CFR-PEEK was recommended in TKA with highly conforming design throughout in-vitro wear testing.20 Therefore, CFR-PEEK

could be an appropriate material for mobile-bearing TKA with high conformity design. However, with respect to mobile-bearing TKA, there is no reference for the biomechanical effect in terms of the change in the tibial insert material from UHMWPE to CFR-PEEK. The aim of this study involves evaluating the biomechanical effects of UHMWPE and CFR-PEEK tibial materials on rotating platform mobile-bearing TKA. The forces on quadriceps, a collateral ligament and a patellar tendon were evaluated under a deep-knee-bend condition.

2. Methods 2.1. Development of three-dimensional knee joint model The previously validated knee joint finite element (FE) model and method were used in the present study.21e23 An FE model for knee joints with accurate anatomy was developed by using the medical image of a healthy and skeletally mature young male athlete without any history of knee disease. The FE model was obtained by conducting computed tomography (CT) and magnetic resonance imaging (MRI). Specifically, CT imaging was performed with 0.1 mm slice thickness by using a 64-channel CT scanner. A MRI was performed by using a 3.0 T MRI scanner and a custom designed knee joint cadio coil.22 MRI scans were obtained with 0.4 mm slice thickness in the sagittal plane. Highresolution settings were used for the spectral presaturation inversion recovery (SPIR) sequence (TE: 25.0 ms, TR: 3590.8 ms, acquisition matrix: 512  512 pixels, NEX: 2.0, field of view: 140  140 mm) and 3-T MRI system, respectively.22 The medial images were processed and segmented by using software (Mimics 17.0, Materialise, Leuven, Belgium) to generate three-dimensional (3D) structures of the lower extremities. The reconstructed CT and MRI models were combined with the positional alignment of each model by using a commercial software (Rapidform version 2006; 3D Systems Korea Inc., Seoul, South Korea) that modeled bony structures as rigid bodies (Fig. 1).24 The cartilage was modeled as isotropic while the menisci were modeled as transversely isotropic with linear elastic material properties.25 In order to simulate meniscal attachments, each meniscal horn was fixed to the bone by using linear spring elements (“SPRINGA” element type) with a total stiffness of

Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010

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Effect of insert material, collateral ligament, and patellar tendon

Figure 1 Developed 3D FE intact knee joint model used in this study.

2000 N/mm at each horn.26 The major ligaments were modeled with nonlinear and tension-only spring elements.27,28 The force-displacement relationship based on the functional bundles in the actual ligament anatomy is expressed as follows: 8 kε2 > > < 0  ε  2ε1 4ε1 ε > 2ε1 fðεÞ Z ; > kðε  ε1 Þ > ε<0 : 0 εZ

l  l0 l0

lr l0 Z εr þ 1 where f(ε) denotes the current force, k denotes stiffness, ε denotes strain, and ε1is assumed as constant at 0.03. The ligament bundle slack length (i.e., l0 ) is calculated by using the reference bundle length lr and reference strain εr in the upright reference position. The interfaces between cartilage and bones are modeled as fully bonded. The contacts between the femoral cartilage and meniscus, meniscus and tibial cartilage, and femoral cartilage and tibial cartilage are modeled for both the medial and lateral sides, and these results in six contact pairs.21 The contacts at all articulations adopted a finite sliding frictionless hard contact algorithm without any penetration.21 Convergence was defined as a relative change of more than 5% between two adjacent meshes.

2.2. Development of the TKA model The surgical simulation for TKA was performed by two experienced surgeons (the second and fourth authors) by using the developed TKA models with different tibial insert

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materials. Computer-assisted design models of a mobilebearing rotating platform from LCS (Johnson & Johnson DePuy Orthopaedics, Inc., Warsaw, IN, USA) were virtually implanted into the bone geometry. A large size femoral component and size 4 tibial baseplate for mobile-bearing TKA were selected based on the dimensions of the femur and tibia, respectively. Based on the conventional surgical technique, the femoral and tibial components were orthogonally inserted with respect to the mechanical axis. This configuration represents a balanced knee joint as illustrated in Fig. 2. Contact conditions were applied between the femoral component, tibial insert and patellar button in the TKA. The coefficients of friction between the articulating surfaces were assumed as 0.07 and 0.04 for the UHMWPE and CFR-PEEK, respectively, based on the range reported in extant studies.29e31 The femoral, tibial, and patellar components and bone cement were composed of a cobalt chromium alloy (CoCr), titanium alloy (Ti6Al4V), UHMWPE, and poly (methyl methacrylate) (PMMA), respectively. The tibial inserts were composed of UHMWPE and CFR-PEEK. In a manner similar to previous studies, the materials were assumed as homogeneous and isotropic.17,32e35 The material properties in terms of the Young’s modulus (E ) and Poisson’s ratio (v) were as follows: CoCr: E Z 220 GPa and v Z 0.3; UHMWPE: E Z 685 MPa and v Z 0.47; CFR-PEEK: E Z 18,000 MPa and v Z 0.4; Ti6Al4V: E Z 110 GPa and v Z 0.3; and PMMA: E Z 1940 MPa and v Z 0.4.17,31e35 A cement layer was considered with a constant penetration depth of 3 mm into the bone (based on different cementing techniques) at the femoral, tibial, and patellar resection surfaces in contact with the femoral, tibial, and patellar components, respectively.36,37 The interfaces between the prosthesis and bone were rigidly fixed by using bone cement.34,38

2.3. Loading and boundary conditions The TKA models with different tibial insert material topologies provided six degrees of freedom to the tibiofemoral (TF) and patellofemoral joints. The FE analysis included three types of loading conditions corresponding to the loads used in the validation experiments with the intact and TKA models and in the simulation under deep knee-bend loading conditions. Under the first loading condition, 1,150N was applied to the model to evaluate the contact stresses and compare them to previous FE studies on the knee joint.26 Under the second loading condition, the TKA model was validated by comparing it to the experiments result in a previous study.39 An anterior force of 133 N and posterior force of 89 N were applied to 30 and 75 flexions, and this followed by measuring the total AP displacement to validate the mobile-bearing TKA model.39 The third loading condition corresponding to deep-knee-bend loading was applied to evaluate the change in the insert material. Computational analysis was performed with the application of an anteriorposterior force to the femur with respect to the compressive load applied to the hip.40e42 A proportional-integralderivative controller was incorporated into the computational model to control the quadriceps in a manner similar to that in a previous experiment.43 A control system was

Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010

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Y.-G. Koh et al.

Figure 2

Developed 3D FE TKA model based on the conventional surgical technique.

used to calculate the instantaneous quadriceps muscle displacement required to match a target flexion profile, and this was the same as that in the experiment. Internalexternal and varus-valgus torques were applied to the tibia.40e42 The FE model was analyzed by using ABAQUS software (version 6.11; Simulia, Providence, RI, USA). We investigated forces on quadriceps, collateral ligament and patellar tendon with UHMWPE and CCFR-PEEK tibial insert materials under the deep-knee-bend condition.

3. Results 3.1. Validation of the intact and TKA model The intact model was validated by a comparison with the previous computational studies. Average contact stresses of 3.1 MPa and 1.53 MPa were found on the medial and lateral meniscus, respectively, under an axial load of 1,150N. Both were within 6% of the 2.9 MPa and 1.45 MPa contact stresses reported by Pen ˜a et al.26 These minor differences could be due to the geometric variations between these studies, such as the thickness of the cartilage and meniscus. Overall, however, the considerable consistency between the validation results and previous studies confirms the validity of the results in this study. Additionally, the TKA model was validated by a comparison with the experimental results obtained by previous studies.39 In the FE model used for the TKA, the anterior-posterior translations in the TF joint were 8.7 mm and 7.3 mm at 30 and 75 flexions, respectively (Fig. 3). These results indicated a good agreement with those of a previous study involving the use of experiments within ranges of values under identical loading conditions that are applied to the prosthesis.39

3.2. Comparison of forces on quadriceps, collateral ligament and patellar tendon for UHMWPE and CFRPEEK tibial insert materials Fig. 4 shows the force on the quadriceps for CFR-PEEK and UHMWPE models under deep-knee-bend conditions. The highest forces of the lumped quadriceps were required in the UHMWPE model under the deep-knee-bend condition. However, the CFR-PEEK required 310 N less forces when compared with UHMWPE in deep flexion. In both models, the quadriceps forces were similar for the low flexion angle. Forces on the medial and lateral collateral ligaments for CFR-PEEK and UHMWPE models under deep-knee-bend condition are shown in Fig. 5. A complex pattern was observed with respect to the force on collateral ligament unlikely to quadriceps force. The force on the medial

Figure 3 Comparison of anterior-posterior translation in the TF joint at 30 and 75 flexions with previous experiment study for validation of TKA model.

Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010

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Effect of insert material, collateral ligament, and patellar tendon

Figure 4 Differences in the quadriceps muscle force for UHMWPE and CFR-PEEK tibial insert materials under the deepknee-bend condition.

collateral ligament for CFR-PEEK exceeded that in the UHMWPE while the force on the lateral collateral ligament for UHMWPE exceeded that for CFR-PEEK. From the mid flexion angle, a change in medial collateral ligament was observed, and it was 11% higher in the CFR-PEEK than in the UHMWPE. With respect to the high flexion angle, a change in the lateral collateral ligament was observed, and it was 8% higher in the UHMWPE than the CFR-PEEK. Fig. 6 shows the force on the patellar tendon for CFRPEEK and UHMWPE models under deep-knee-bend conditions. Similar trends were observed in forces on the patellar tendon and quadriceps. A 16% lower force was observed in the CFR-PEEK than UHMWPE under the deep-knee-bend condition.

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favorable outcomes with respect to the dislocation of the bearing, and this is a complication specific to the mobilebearing TKA.8,44 A TKA is increasingly common for younger patients, and therefore, it is necessary for artificial joints to last for several more years when compared with currently used designs.15 In artificial hip and knee joints implanted in patients under the ages of 50 and 55 years, 30.7% and 15% of the patients exhibited failure after 15 and 14 years, respectively, thereby leading to revision surgery.45 With respect to patients of all ages, failure is commonly observed as a result of aseptic loosening and tibial insert wear.46 Furthermore, such problems occur more frequently in mobile-bearing TKA, especially abrasion of the undersurface of the insert is also reported to occur with the mobile-bearing TKA since its insert involves contact with both femoral and tibial components.47 Pin-on-plate studies demonstrated that UHMWPE provides reduced wear with increases in contact pressure, and thus, a low conformity-fixed-bearing TKA with lower contact area and higher contact pressure is observed to exhibit lower wear when compared with that of a more conforming implant given all other parameters are fixed.48,49 However, there is a concern that the body’s biological reaction to UHMWPE wear particles leads to bone resorption and subsequent loosening and failure of the joints.47 Moreover, delamination of the UHMWPE tibial bearing surface is also observed to occur leading to failure of conventional

4. Discussion The most important finding of the study is the positive biomechanical effect observed in the CFR-PEEK tibial insert when compared to the UHMWPE in the rotating platform mobile-bearing TKA. Although mobile-bearing TKA favorable long-term outcomes were reported, it is suggested that clinical symptoms and long-term outcomes did not exhibit a difference when compared with a conventional fixed-bearing TKA.3e6 Additionally, the mobile-bearing TKA did not exhibit more

Figure 6 Differences in the patellar tendon force for UHMWPE and CFR-PEEK tibial insert materials under the deepknee-bend condition.

Figure 5 Differences in the (a) medial collateral ligament force and (b) lateral collateral ligament force for UHMWPE and CFRPEEK tibial insert materials under the deep-knee-bend condition.

Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010

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6 joints.50 The alternative material for UHMWPE could lead to a reduction in osteolysis, and therefore an increase in joint life expectancy. The TKA simulation indicated the CFR-PEEK in conforming partial knee replacements, total hip replacements, and a horse-shoe shaped tissues paring cup design. Hip wear simulation studies with both conventional and horse-shoe cups indicated favorable wear performance of CFR-PEEK when examined with ceramic femoral heads and compared with UHMWPE.51,52 The conforming partial knee replacement experimental studies indicated that the CFR-PEEK exhibited an equivalent or lower wear performance when compared with that of the standard bearing arrangement.14,53 The potential wear advantage of CFR-PEEK bearings in TKA appear more clearly demonstrated in ceramics on CFR-PEEK hip replacements to date.51 The previously mentioned studies suggested that design is a more important factor although CFR-PEEK is considered as alternative material to UHMWPE.14,51,54 Additionally, the results commonly indicated that CFR-PEEK led to better wear performance when compared with the UHMWPE in conformed design.14,51,54 Mobile-bearing TKA is generally considered as a design that exhibits good conformity between a femoral component and a tibial insert.3e6 Therefore, CFR-PEEK is most appropriate in mobile-bearing TKA. However, to the best of the authors’ knowledge, extant studies did not evaluate biomechanical effect with respect to the change in material from UHMWPE to CFR-PEEK in mobile-bearing TKA. Therefore, this study involved investigating the biomechanical effect in material change from UHMWPE to CFR- PEEK by using a 3D nonlinear FE model. We developed a 3D nonlinear FE model of a knee joint with bony structures and soft tissues. The advantage of the computational simulation that uses a single subject is that it is possible to determine the effects of tibial insert materials on the same patient and exclude other variables such as weight, height, bony geometry, ligament properties and component size.54 Additionally, biomechanical studies typically use cadavers of older individuals. Hence, if these are repeatedly exposed to loading conditions for mechanical studies, then this could result in loosening between the specimen and apparatus as well as attenuation of the tissue itself.55 The intact knee model was subjected to a series of validation steps, and the results indicated good agreement with previous experiments and those of the experiment involving the use of the same subject. Furthermore, the TKA model used in the study was validated with previous experimental data. Therefore, TKA models with different tibial insert materials developed in the study and the simulation results are considered as reasonable. We investigated forces on quadriceps, a collateral ligament and a patellar tendon with respect to a deep-knee-bend condition. The results revealed that the CFR-PEEK required less quadriceps force to reach same flexion angle when compared with the UHMWPE. Increased quadriceps strength leads to functional performance improvement.56 Osteoarthritis patients and TKA patients experience significant quadriceps weakness, and thus CFR-PEEK tibial insert material decreases the required quadriceps force, and thus it may be easier for patients to kneel, squat, or rise from a chair.57

Y.-G. Koh et al. An interest finding is that a complex pattern exists with respect to force on a collateral ligament. The force of the medial collateral ligament during a simulated deep-kneebend increased for CFR-PEEK when compared to that for UHMWPE. However, an opposite trend was observed in the lateral collateral ligament. In clinical practice, a successfully balanced extension gap with any further material change alters the level of the tibiofemoral joint line and the complex force on the collateral ligament. Thus, the medial and lateral collateral ligament balance could be an important factor for the medial pivot during knee flexion in TKA. A previous study observed a correlation between medial stability and lateral laxity at the 135 knee position.58 The study concluded that the main aim of surgery should involve achieving stability on the medial side and a few millimeters of laxity on the lateral side in the kneeflexed position.58 As previously mentioned, forces on medial and lateral collateral ligaments are important. However, there was no standards for forces on medial and lateral collateral ligaments. TF joint progressive loosening occurs if the force is excessively low. Conversely, ligament failure occurs if the force is excessively high.59 In CFR-PEEK, stability should be achieved on the medial side and a few millimeters of laxity should be achieved on the lateral side in the knee-flexed position when compared to the UHMWPE. Similar trends were observed in the patellar tendon and quadriceps forces. The patellar tendon force on the CFR-PEEK was lower than that in the UHMWPE. Clinically, a more posterior contact position between the tibiofemoral components leads to an increase in the quadriceps lever arm, and this improves the movement efficiency and contributes to reduced quadriceps force and patellar tendon force. Therefore, several manufacturers attempted to increase the quadriceps lever arm in the design. However, the results indicated that CFR-PEEK provided a positive biomechanical effect when compared with the UHMWPE. There are two limitations. First, additional simulations other than deep-knee- bend simulation related to more demanding activities such as rising from a chair, sitting and climbing and descending stairs are required. However, simulation for deep-knee-bending motions still includes motion in both a wide range of flexion/extension and significant muscular endeavor around the knee joint. Second, the results cannot be generalized in clinical perspective and do not include patient satisfaction because they solely relied on the computational analyses. Moreover, clinical data is required for clinical application of CFR-PEEK insert. However, the main factor analyzed in the present study corresponds to the main investigating components in evaluating the biomechanical effect of computational biomechanical.21e24,35,44,55,59

5. Conclusions In conclusion, we investigated the biomechanical effect with respect to material change from UHMWPE to CFR-PEEK in the conforming design of mobile-bearing TKA in which it is clinically possible to use CFR-PEEK as a tibial insert

Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010

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Effect of insert material, collateral ligament, and patellar tendon material. The results indicated that CFR-PEEK is an alternative material to UHMWPE because it improves the biomechanical effect in the present study and it also enhanced the wear performance as indicated in a previous study. The use of CFR-PEEK contributed to improve the exercise efficiency of the quadriceps muscle and to reduce the patellar tendon force. These investigations could constitute important procedures to ensure patient satisfaction and improve postoperative performance.

Declaration of Competing Interest The authors report no conflict of interest.

Acknowledgments No external source of funding was received for the study.

List of abbreviations TKA total knee arthroplasty UHMWPE the ultrahigh-molecular-weight polyethylene PEEK polyetheretherketone CFR-PEEK carbon fiber reinforced-PEEK FE finite element CT computed tomography MRI magnetic resonance imaging SPIR the spectral presaturation inversion recovery 3D three-dimensional

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Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010

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Please cite this article as: Koh Y-G et al., Effect of insert material on forces on quadriceps, collateral ligament, and patellar tendon after rotating platform mobile-bearing total knee arthroplasty, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.09.010