BACKGROUND

UKA is functionally superior to TKA, with kinematics similar to native knees, nevertheless, UKA implants are used in less than 10% of cases. While advantages of UKA are recognized, ACL-deficiency is generally considered a contraindication. The hypothesis of this study was that fix bearing UKA in ACL-deficient knees, with appropriate adaptation of implant placement, would result in similar kinematic trends to conventional UKA with an intact ACL.

Introduction

Patellofemoral complications remain a very common post-operative problem in association with total knee arthoplasty (TKA). As malrotation of the femoral component is often considered crucial for the outcome, we analyzed absolute rotational femoral alignment in relation to patellar tracking pre- and postoperatively and matched the results with the two year functional outcome.

Introduction

Patellar tracking in total knee replacements has been extensively studied, but little is known about patellar tracking in isolated patellofemoral replacements. We compared patellar tracking and the position of the patellar groove in the natural knee, followed by implantation of the femoral component of a PFR (patella unresurfaced) and after implantation of the femoral & patellar component of the PFR.

Introduction

Mobile-bearing TKRs allow some axial rotation and may provide a more natural patellar movement. The aim was to compare patellar kinematics among the normal knee, fixed-bearing and mobile-bearing TKR.

Introduction: Mobile bearing TKRs may allow some axial rotation and also compensate for a slight tibiofemoral rotational mismatch. This is thought to provide better kinematics and a more natural patellar movement. This theoretical advantage has not been verified in clinical studies for the tibiofemoral kinematics. However, little is known about the patellofemoral kinematics of mobile bearing TKRs. The aim was to compare patellar kinematics among the anatomic knee, fixed bearing TKR and mobile bearing TKR.

Methods: Optical computer navigation marker arrays (Brainlab) were attached to the femur, tibia and patella of 9 whole lower extremities (5 fresh cadavers). The trial components of a fixed bearing posterior stabilised TKR (FB) (Sigma PFC, Depuy) were implanted using a tibia first technique. Then the tibia component was changed to a posterior stabilised mobile bearing tibia component (MB) (Sigma RP Stabilised). The patellae were not resurfaced. The knees were moved through a cycle of flexion and extension on a CPM machine. Medial/lateral shift and tilt was measured relative to the patella position in the natural knee at full extension always with soft tissue closure. The path of the trochlea and patellar groove of the femoral component was registered. Values are expressed as mean+/−one standard deviation. Statistical analysis: two tailed paired Student’s T-test.

Results: M/L shift: There was a tendency for the patella to track 2mm more laterally throughout the flexion range with a FB or MB TKR compared to the natural knee, but this did not reach significance.

Tilt: The patella in the natural knee tilted progressively laterally from extension to flexion, plateauing at 50° of flexion (20°: 1.9+/−2.7°, 40°: 5.6+/−5.4°, 60°: 6.2+/−6.4°, 80°:6.5+/−7.3°, 90°: 6.4+/−7.7°). With a FB or MB TKR the patellae also tilted laterally up to 50 degree of flexion, but then started to tilt back medially, reaching the neutral position again at 90°. The patellae of the FB and MB TKRs were significantly more medially tilted at 50° to 90° of flexion compared to the natural knee. But there was no difference between the FB and MB TKRs. (Fixed bearing: 20°: 2.5+/−7.2° p=0.30, 40°: 3.7°+/−6.5° p=0.15, 60°: 3.1+/−5.8° p=0.02, 80°:1.2+/−6.5° p=0.001, 90°: 0.3+/−7.2° p=0.001, Mobile bearing: 20°: 0.3+/−5.5° p=0.27, 40°: 3.6+/−5.2° p=0.08, 60°: 2.1°+/−5.8 p=0.01, 80°: 0.2+/−6.8 p=0.003, 90°: −0.6+/−7.3 p=0.002; vs. natural)

Trochlea position: The centre of the patellar groove of the femur component was more lateral than the trochlea by 2–5mm, it also extended 10mm further proximally.

Conclusion: There are kinematic differences in patellar tracking between the natural and a FB/MB TKR. This may be due to a slightly different position of the patellar groove. The patellar kinematics of the MB TKR is not more natural compared to the FB TKR.

Introduction: Rotational alignment of the femoral component is widely believed to be crucial for the ultimate success of total knee arthroplasty (TKA). However there is a paucity of normative data on femoral component rotation in ‘perfect’ TKA.

Methods: Femoral component rotation in well-functioning TKA was assessed by means of axial radiography as described by Kanekasu et al. Well-functioning TKA were defined by three criteria at 5-year follow-up:

Knee Society objective and functional score of 190 or above

Thirty TKA of 29 patients (9 male, 20 female) with a median age of 70 years (range, 31–87) at time of surgery fulfilled the study criteria. All TKA were implanted at a single high-volume joint replacement center in 2002. In all cases both the condylar twist angle (CTA) using the clinical epicondylar axis (CEA) and the posterior condylar angle (PCA) using the surgical epicondylar axis (SEA) were used to assess rotational alignment of the femoral component.

Results: Overall, the mean CTA was 3.6+−3.5° of internal rotation (IR) (range, 4.1° of external rotation (ER) to 8.6° of IR) for the femoral component. For females, the CTA had a mean value of 4 +/−3.7° of IR (range, 7.6° of IR to 4.1° of ER) compared to 2.3 +/−3° of IR (range, 5.3° of IR to 2.5° of ER) in males. Overall, the mean PCA was 1.5 +/−3.5° of ER (range, 8.4° of ER to 5.1° of IR). In females, the mean PCA was 1 +/−3.9° ER (range, 2.3° of IR to 5.8° of ER) compared to 2.8 +/−2° ER (range, 0.4° of ER to 5.7° of ER) in males. The mean angle between CEA and SEA was overall 5.1 +/−1.8° (range, 3.3° to 9.1°), in females 5.1 +/−1.6° (range, 3.5° to 9.0°) compared to 5.0 +/−2.4° (range, 3.2° to 9.1°) in males.

Conclusion: Well-functioning TKA demonstrated a highly variable rotational alignment of the femoral component ranging from excessive external rotation to excessive internal rotation. These findings challenge current reference values for optimal femoral component rotation.

Introduction: Since the introduction of the Zimmer Innex UCOR (Ultra COgruent Rotating) mobile bearing total knee arthroplasty (TKA) system in 1999, there were close to 3000 primary TKAs performed at our institution utilizing this implant. We report on the first 396 5-year follow-up results and overall revisions in our total collective.

Methods: Between 1999 and 2006 there were 2734 primary Innex UCOR TKA performed (1748 female/987 male) at the Schulthess Clinic, Zurich. Primary diagnosis leading to TKA were OA (2462 – 90%), RA (144 – 5.3%), posttraumatic arthritis (65, 2.4%), necrosis (50, 1.8%) and misc causes (13 – 0.5%). The mean age of the females patients was 69y (33y – 92y), and 68y (31y – 93y) in the male population. To date 396 knees underwent clinical and radiological follow-up at 5 years (mean 5y 0m, range 4y 1m – 7y 2m), with 5% of the patients being lost to follow-up. Scoring was done, using the Knee Society Score (KSS). All patients had a full leg radiograph pre-operatively as well as at follow-up.

Results: Total KSS improved from 106.5 (6 – 184) pre-operatively to 179.5 (80 – 200) at follow-up, the knee score from 42.2 (2–93) to 92.1 (37 – 100), the function score from 64.3 (0–100) to 87.4 (10–100) respectively. The pain score increased from 17.7 (0–50) to 47.5 (20–50, 50 points maximum). ROM pre-operatively was 104.6° (0–145) and reached 117.2° at follow-up (55–145). Subjective evaluation by the patient at 5 years was excellent and good in 91%, fair in 8% and taxed poor by 1% of the patients. 95% of full leg radiographs showed a femorotibial angle of 182°–188°, 3% were < 182° (varus), 2% > 188° (valgus). Overall revision rate (95 of 2735) was 3.5%, 1.1% for infections and 1% for anterior knee pain and/or patella pathology. 0.6% were revised for instability, 0.3% for arthrofibrosis, and the remaining 0.5% for various problems.

Conclusion: These promising 5 year observations with the Innex UCOR mobile bearing TKA system suggest favorable overall midterm results. Further longer term follow-up evaluations are scheduled while 5 year follow-ups are ongoing, allowing for continuing reports on long-term performance.

Introduction: Stiffness after primary total knee arthroplasty (TKA) is a severe complication that has been associated with excessive internal rotation of the femoral component.

Methods: Between 2001 and 2004, 18 patients with 18 well-fixed, aseptic primary TKA underwent revision TKA at a single high-volume joint replacement center for stiffness in the presence of femoral component mal-rotation. Stiffness was defined as ROM with less than 90° of maximum flexion or a flexion contracture greater than 10°. Femoral component malrotation was defined as a condylar twist angle of more than 4° of internal rotation using CT scans. Following IRB approval, 17 out of 18 patients (median age at time of the index surgery 62.7 years, range 45 to 78; female, n=11; male, n=6) were available for retrospective outcome assessment. The mean time between primary and revision TKA was 3.2 years (range, 9–79 months). At a mean follow-up of 3.3 years (range, 2 to 6), all patients were evaluated clinically using the Knee Society objective and functional scores, and by CT measurement of femoral component rotation. Patients without additional procedures between primary and index revision TKA (group A, n=9) were compared using Student t-testing with those which had undergone additional interventions (group B, n=8).

Results: Five patients had required additional procedures after the index revision TKA including closed manipulation under anesthesia in one case, patellar resurfacing in one case, metal removal after tubercle osteotomy and open debridement in another case, and tibial component revision followed by revision TKA in one case. CT scans after revision TKA revealed correction of femoral component rotation in all but one case from each group. After revision TKA, the mean objective score was overall 73 points, in group A 82 points compared to 63 points in group B (p< 0.001). In group A there were 78% excellent or good results compared to 13% in group B. The mean function score was overall 74 points, 78 points in group A compared to 69 points in group B. There were 67% good or excellent results in group A compared to 12% in group B. Mean flex-ion increased overall from 71 to 92 degrees (p< 0.01), in group A from 61 to 96 degrees (p< 0.01) and in group B from 82 to 89 degrees. Mean flexion contracture was reduced overall from 7 to 4 degrees, in group A from 6 to 3 degrees, and in group B from 8 to 5 degrees. Stiffness persisted in four cases (24%) (group A, n=1; group B, n=3). Satisfaction (VAS 0–100; 100=completely satis-fied) scored overall a mean of 52 points, in group A 57 points and in group B 44 points.

Conclusion: Overall, revision TKA for knee stiffness associated with femoral component internal malrotation resulted in significantly improved knee motion. However, outcome was less predictable in those patients with additional procedures between primary and revision TKA.