Mastering Orthopedic Techniques Total Knee Arthroplasty Rajesh Malhotra
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Design Principles1

Amrit Goyal,
Jose A Rodriguez
 
Introduction
A successful total knee replacement requires the surgeon to have a thorough knowledge of the knee implants. Most of the design principles elucidated in the early attempts at implant design remain valid and in clinical use even today. This chapter gives a brief overview of the basic design principles of the knee implants.
 
Early Attempts
The earliest reported surgery for the arthritic knee goes back to 1861 when Fergusson1 performed a resection arthroplasty for the knee joint. Interpositional arthroplasties were attempted with various materials, like joint capsule (Verneuil in 1863), muscle (Ollier), fascia (Murphy) and free fascial grafts (Campbell), but were not successful.2
Hemiarthroplasty of the knee was used by Campbell3 in the form of a vitallium mold arthroplasty for femur in 1940. MacIntosh4 used an acrylic tibial hemiarthroplasty for treating painful varus and valgus deformities. These procedures showed early clinical improvements but failed later because of implant loosening and progression of arthritic disease in the unreplaced articular surfaces.
 
Hinged Implants
Hinged knee designs are mechanically linked together providing intrinsic stability. A hinged knee design was first made commercially available by Walldius in 1951 in acrylic and later made in stainless steel and cobalt chrome.5 The knee is a kinematically complex joint with different radii of curvatures during flexion and extension. The uniaxial hinge designs had an early failure as they did not reproduce the complex motion of the knee joint.6 Improper sizing, lack of rotational freedom and absence of patellofemoral replacement also contributed to their failure.7 The long intramedullary stems were subjected to considerable torsional stresses, especially in flexion. These interface stresses generated by the complete constraint of the articulations led to the structural failure of these early hinged implants.5 Uniaxial stainless steel implant design of Shiers8 failed mechanically at the stem hinge interface in 1960.
The Guepar prosthesis was designed with a posteriorly offset hinge center of rotation to increase the range of motion. Minimum bone cuts were taken to allow salvage arthrodesis, if required. A polyethylene stop was also used to absorb shock in full extension. Patellofemoral complications were also reduced when it incorporated a trochlear groove and had seven degrees of valgus tilt in the femur.9 It had better results than the early hinge designs, but the incidence of infection and mechanical failure of the stem were still unacceptably high.10
2
The spherocentric knee was a constraint relieving modified hinge design with intrinsic stability. It had a ball and socket joint with triaxial rotation and cam deceleration but required large bony resection. It was recommended for patients with severe deformity or instability.11
 
Newer Hinge Prosthesis
The kinematic rotating hinge (KRH) knee prosthesis (Howmedica, Rutherford, NJ) is a hinged device with rotational freedom allowing axial rotation along the central axis of the tibia. This decreases the high interface stresses which led to the failure of the early fixed hinged devices.12 Rand et al still found a high incidence of complications such as sepsis (16%), patellar instability (22%), and mechanical failure (6%) with these implants. They recommended its usage only in cases with severe collateral ligament insufficiency not amenable to soft tissue reconstruction.13 Springer et al also recommended its use only as the final salvage option for complex primary or salvage revision of total knee arthroplasty.14
 
Bicompartmental Prosthesis
The evolution of the total knee prostheses designs from 1970 to 1980 hinged around the anatomic approaches or the functional approaches (Fig. 1.1).
Gunston, in early 1970, was the first who designed a polycentric knee implant which sought to reproduce the polycentric motion of a normal knee joint. He used semicircular stainless steel femoral components each articulating with a high density polyethylene tibial component fixed to bone with polymethylmethacrylate cement. This design required minimal bone resection and had minimal constraint. The stability to the knee joint was provided by the retained cruciate and collateral ligaments.15 Malalignment due to inadequate soft tissue releases and subsequent loosening was the major cause of failure of these implants.16
Robert Averill developed the dual-conforming bearing mechanism with preservation of cruciates. Medial and lateral bearing surfaces of femoral and tibial components in this design, called Geomedic knee (Fig. 1.2) were symmetrical and parallel.
Coventry et al developed a two component cemented knee implant, called the geometric knee, with a single tibial and femoral component. The cruciate ligaments were also retained in this design. The high degree of femorotibial conformity in this design with cruciate retention led to kinematic incompatibility, reduced range of motion and early loosening.17
The duocondylar knee had condylar-shaped femoral components connected with a metal bar in the center (Figs 1.3A to C). These articulated with two separate flat tibial plateau implants providing the design of a low conformity. This design was also minimally constrained and depended on the cruciate, and the collateral ligaments to provide soft tissue stability.18 The unreplaced patellofemoral joint sometimes led to pain and was one of the problems in this design. Also the flat tibial surfaces were subjected to tilting or loosening with any off center load because of the small surface area and no additional fixation of the flat tibial surfaces. Since the cruciates were retained, complete correction of severe deformities was sometimes not possible.19
Freeman et al20 were the first who sacrificed both the cruciate ligaments and the described concept of soft tissue ligament balancing. They used a roller in trough design called the ICLH (Imperial College London Hospital) Knee (Fig. 1.4). They also emphasized on various design principles for implant prosthesis which are still valid to date. They are:
  1. Minimal bony resection so as to allow a later salvage arthrodesis if required.
  2. Minimize chances of loosening by using–
    1. Minimal femorotibial constraint to decrease the interface stresses that led to the loosening of the prosthesis-skeletal bond.
    2. Low friction between the two surfaces.
    3. Progressive hyperextension limiting mechanism and not sudden.
    4. Load distribution over the largest possible bone prosthesis interface possible.
  3. Minimal wear debris production by use of large metal on plastic bearing surfaces.
  4. Minimal dead space to prevent infection.
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    FIGURE 1.1: The evolution of the condylar total knee from 1970 to 1980. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
  5. Avoidance of intramedullary stem and intramedullary cement to prevent infection propagation.
  6. Development of a protocol and surgical technique for standard insertion procedure.
  7. Range of motion of prosthesis should at least be from 5 degrees of hyperextension to 90 degrees of flexion.
  8. Restriction of some freedom of rotation.
  9. Use of soft tissue ligament tension and collateral ligaments to provide stability and restraint to the prosthesis.
Absence of central tibial prosthetic eminence in Freeman-Swanson knee (Fig. 1.5) led to mediolateral instability and implant failure.
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FIGURE 1.2: The Geomedic knee. Note the added anterior dovetail tibial peg. The knee was later called Geometric by surgeons. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
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FIGURES 1.3A TO C: Implantation of the duocondylar knee (Courtsey: Dr CS Ranawat)
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FIGURE 1.4: Skyline view of the ICLH prosthesis. Note the absence of mediolateral patellar constraint resulting in patellar instability. (Reprinted from “Freeman MA, Samuelson KM, Elias SG, Mariorenzi LJ, Gokcay EI, Tuke M. The patellofemoral joint in total knee prostheses: Design considerations. J Arthroplasty 1989;4(Suppl): S69-74, Copyright (1989), with permission from Elsevier”)
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FIGURE 1.5: The Freeman Swanson knee. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
 
Tricompartmental Prosthesis
The total condylar prosthesis was the first to replace all the condylar surfaces including the patellofemoral joint (Figs 1.6 and 1.7A, B). The design geometry was of low conformity and was stabilized by collateral ligaments and capsular soft tissue tension. The femoral component was of cobalt chrome articulating with the high density polyethylene tibial and patellar components. The femoral component was anatomically shaped with a grooved flange for patella. Tibial fixation was enhanced with a stout central fixation peg which required excision of the cruciate ligaments. Cement fixation was used which also eliminated micromotion by filling bone-prosthesis mismatch areas. The tibial articular surface was cupped and had a median intercondylar eminence that along with the collateral ligament tension resisted anterior, posterior or rotary subluxation.21
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FIGURE 1.6: The total condylar knee. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
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FIGURES 1.7A and B: (A) Anteroposterior view of a total condylar knee radiograph at 21 years of follow-up. (B) Lateral view of a total condylar knee prosthesis at 20 year of follow-up
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FIGURES 1.8A and B: The total condylar II implant. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
The total condylar knee prosthesis II was developed with a longer tapered tibial post to prevent posterior subluxation in cases of instability (Figs 1.8A and B). It however, did not provide any mediolateral or rotatory constraint.
The total condylar knee prosthesis III was further constrained for difficult revision surgeries and unstable knees. It had a non-tapered wide tibial post-articulating with the femoral recess providing both anteroposterior and mediolateral stability. It also had an option for femoral stem and can be called the forerunner of the current constrained condylar knee (CCK).22
The Duopatellar prosthesis was modified from the Duocondylar prosthesis to include a patellofemoral articulation (Fig. 1.9). The tibial component was converted to a single piece with a central fixation peg and a posterior cutout for retaining the posterior cruciate ligament. The anterior femoral flange was elongated to allow articulation with the dome shaped patellar component.23,24
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FIGURE 1.9: The Duopatella knee. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
Most of the current surface replacement designs are based on the principles used in the early designs. The total condylar evolved into the posterior cruciate substituting design and the duopatella into the posterior cruciate retaining design.24 The Kinematic cruciate retaining design also evolved from the duopatellar knee.25
Some of the limitations noted with the total condylar prosthesis included an average post-operative motion of 90 degrees in most early studies, and rare cases of posterior subluxation in cases of severe deformity with subsequent flexion laxity. The posterior stabilized prosthesis was introduced by Insall and Burstein in 1978 to circumvent this problem. They used a transverse cam on femoral surface with a central polyethylene tibial post to provide posterior stability. They also put a 7 degree tibial slope which along with the cam mechanism helped to achieve an average of 25 degrees more flexion than the total condylar prosthesis.26
Bartel recommended metal backing of the tibial component whenever there was insufficient supporting tibial surface. Metal backing also fractionally reduced compressive forces on the tibial cancellous bone compared to the all polyethylene tibia27 (Fig. 1.10).
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FIGURE 1.10: Metal backed polyethylene insert
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FIGURE 1.11: The Insall-Burstein Posterior-Stabilized (IBPS) knee. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
The Insall-Burstein posterior stabilized implant was manufactured with compression molded polyethylene fixed onto a titanium baseplate (Fig. 1.11).
The Insall-Burstein Posterior Stabilized II (IBPS II) prosthesis (Zimmer Inc, Warsaw, IN) incorporated design modifications that improved patellar tracking such as use of symmetric femoral components and a deeper patellar groove (Fig. 1.12). Knee flexion was also increased to 125 degrees by increasing the height of posterior femoral flange. The knee implants were also made modular, allowing exchange of the polyethylene inserts and use of stems and augments to compensate bone loss.28
The IBPS II knees were stable in midflexion but had increased rates of dislocation with maximum flexion. This design was modified by slight anterior placement and increasing the height of the tibial spine by 2 mm each. This so called 2 + 2 modification minimized its chances of dislocation with maximum flexion but also decreased the average flexion achieved to 117 degrees29-31 (Fig. 1.13).
The PFC modular knee utilized the same tibial spine–femoral cam mechanism developed at the Hospital for Special Surgery in their posterior cruciate substituting design, further modifying the patellofemoral articulation to be deeper and more conforming within the femoral trochlea.
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FIGURE 1.12: The Insall-Burstein Posterior Stabilized II (IBPS II) prosthesis design - a deeper patellar groove to improve patellar tracking
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FIGURE 1.13: IBPS II “2 + 2 modification” to minimize its chances of dislocation - slight anterior placement and 2 mm increase in the height of the tibial spine
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This was the first knee system to offer both the cruciate substituting design and a cruciate retaining option evolved from the duocondylar knee.32 With better understanding of the patellofemoral biomechanics further modifications were incorporated into most current designs. These include making side specific anatomically oriented deepened trochlear groove in the femoral component to reduce patellar complications. The number of femoral component sizes were also increased to prevent patellar overstuffing due to component size mismatch.33
Most of the current knee implants in use today are either posterior cruciate retaining or substitution designs. The place of the posterior cruciate ligament in total knee arthroplasty is still controversial. Some cruciate sacrificing designs remain, and these usually offer an extended anterior lip to provide resistance to posterior subluxation.
 
POSTERIOR CRUCIATE SUBSTITUTION VS RETENTION
The debate regarding substitution versus retention for the posterior cruciate ligament persists. While favoring the cruciate substituting designs, we have tried to summarize the published literature as follows:
 
RANGE OF MOTION
Various studies have demonstrated no difference in the range of motion of the two designs in the long-term.34,35
 
KINEMATICS
In a healthy knee the posterior cruciate ligament is responsible for the femoral roll back phenomenon.36 The posterior cruciate ligament retaining prostheses have been shown in fluoroscopic studies to demonstrate paradoxical roll forward with anterior translation of the tibiofemoral contact areas even with slight ligament imbalance.37,38 Dennis et al37 have reported that femoral roll back is also reliably seen with the posterior stabilized design. These findings were made in cases that were considered clinically successful, and asymptomatic. Similar studies performed in cruciate substituting knees show reproducible roll back.39
 
GAIT
Many studies support that posterior cruciate ligament retaining prostheses have a more normal gait patterns, especially during stair climbing.40-42 However, Wilson et al found no significant differences in their gait studies with posterior stabilized knee designs.43
 
PROPRIOCEPTION
The posterior cruciate ligament in arthritic knee has been found to be abnormal biomechanically and histologically than would be expected with the normal age-related degeneration.44 Simmons et al did not find any difference in the proprioceptive function after posterior stabilized or cruciate retaining knees.45
 
CORRECTION OF DEFORMITY AND STABILITY
Laskin et al have found better correction of preoperative varus or valgus deformities greater than 15 degrees with posterior stabilized knees.46
Proper balancing of the posterior cruciate ligament is very difficult even in experienced hands. Mahoney et al in their study found that proper function of the posterior cruciate ligament after knee arthroplasty required balancing of collateral ligament and joint line to the accuracy of 1 mm.47
Posterior stabilized implants are technically easier to balance after correction of the deformity.48 Improper balancing of the posterior cruciate ligament can lead to flexion instability if loose or limitation of flexion if it is over tight.49-51
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FIGURES 1.14A and B: Failure of carbon reinforced polyethylene insert
 
POLYETHYLENE WEAR
The cruciate retaining implants have less conforming femorotibial articulation than the posterior stabilized implants. This can lead to higher contact stresses on the polyethylene and cause more deformation and wear in the long-term.52
Improperly balanced posterior cruciate ligament causing limited flexion or excessive rollback can also lead to higher compressive forces and potentially higher polyethylene wear.53 The polyethylene insert has also been shown to have high contact stresses and high wear rate with noncongruent designs than the more congruent ones54 (Figs 1.14A and B). However, Scott et al have shown long-term follow up with PFC cruciate retaining knees with a low incidence of polyethylene wear.55
 
Meniscal Bearing Prosthesis
Increasing conformity of the femorotibial articulation decreases contact stress and polyethylene wear but at the same time also decreases the freedom of motion. The mobile bearing design allows for rotation between the tibial baseplate and the polyethylene insert and can maximize articular conformity with minimal polyethylene wear.48 Goodfellow and O'Conner were the first to use free meniscal bearing fully congruent tibial polyethylene inserts moving on a tibial baseplate. These were held in place by their geometry and ligamentous tension.56-58
This concept inspired Buechel and Pappas to develop the New Jersey LCS knee (DePuy Orthopaedics Inc, Warsaw, Ind) (Fig. 1.15). It had decreasing radii of curvature of the femoral component posteriorly. This lessened chances of meniscal extrusion with increasing flexion but also reduced some congruency. They designed the rotating platform design for cruciate sacrificing implants and meniscal bearing design for bicruciate or posterior cruciate retention implants2,59 (Fig. 1.16).
 
High Flexion TKR
High flexion after total knee arthroplasty is defined as greater than 125° of flexion.
Some modifications are required in the design to achieve this high flexion. The trochlear grove is elongated to prevent patellar catching in the intercondylar groove. The tibial polyethylene insert is recessed anteriorly to prevent impingement of the patella and patellar tendon during deep flexion. In posterior-stabilized designs modifications are made in the cam and post-mechanism to increase the jump distance to prevent dislocation.60,61
The posterior condylar offset has to be re-established to provide a continuous radius of curvature for continued femoral rollback. This helps posterior femoral translation and clearance of the knee with increased flexion (Figs 1.17A and B).
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FIGURE 1.15: The LCS bicruciate knee after bone ingrowth surfaces were added. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
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FIGURE 1.16: The LCS rotating platform knee. (Reprinted from “Robinson RP. The early innovators of today's resurfacing condylar knees. J Arthroplasty 20(Suppl 1):2-26”. Copyright (2005), with permission from Elsevier)
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FIGURES 1.17A and B: (A) Lateral radiograph of a Legacy posterior-stabilized TKA at high flexion demonstrating the limited posterior condylar offset and impingement against the posterior proximal bone. (B) Lateral radiograph of a high-flexion Legacy posterior-stabilized TKA at high flexion demonstrating improved posterior condylar offset. (Reprinted from “William JL, Giles RS. High-flexion total knee arthroplasty. J Arthroplasty 2008;23(7): 6-10. Copyright (2008)”, with permission from Elsevier)
In some designs additional 2 mm of posterior condyles are resected in order to accommodate for the changing radius of curvature posteriorly and allowing articulation into deep flexion, while maintaining the offset posteriorly. This additional 2 mm resection often allows visualization and thereby removal of impinging posterior osteophytes to recreate posterior recess.62
12
 
Cementless Fixation
Cementless fixation requires close bone apposition and initial rigid fixation allowing bone ingrowth into the porous surface.63
Micromotion at the implant bone surface has been shown to be one of the factors for poor bone ingrowth in many cementless designs. The femoral designs require precise femoral preparation and anteroposterior fit to reduce micromotion. There has been high incidence of osteolysis around the screws used for supplemental fixation of the tibial component.64,65 High failure rates demonstrated with metal backed cementless patellar components can be attributed to failure of ingrowth, metallosis and excessive polyethylene wear.66
Hungerford et al suggested that cementless fixation would be more durable than cemented.67 Ritter et al have demonstrated 96.8% survival at 20 years for cementless monoblock tibia without supplemental screw fixation. The cementless designs look promising especially for the younger patients with the advent of newer biomaterials like porous tantalum and hydroxyapatite and highly porous titanium.68 Many other studies have also shown good results with the cementless knee designs.69-71 The reproducibility of non-cemented fixation shown in published studies remains less than of cemented implants.
 
Patellofemoral Design
Patellofemoral problems had been one of the greatest source of complications in the modern total knee arthroplasty.72,73
The patellar designs may be classified as inset or the onlay types or depending on the means of fixation cemented or cementless.
 
INSET PATELLA
The inset patella is designed to provide better resistance to the shear stresses experienced during joint motion on the patella. Freeman et al used a circular single peg cemented inset component and found good results.74
However, no statistical difference has been found between the onlay and the inset designs with regards to the knee joint kinematics and patellofemoral tracking.75 Also no difference in the stair climbing ability or anterior knee pain has been found between the two devices. A higher incidence of radiolucent lines has been seen in the inset patella compared to the onlay design. Salvage of the patellar component is also difficult with inset patella in case of loosening as more bone stock is removed during its preparation.76
 
ONLAY PATELLA
Most commonly used onlay patella was dome shaped and had a large central fixation peg. An anatomic design has also been used but requires precise rotatory alignment. The more congruent oval or sombrero shaped patella are supposed to have better wear rates than the traditional dome shaped patella. They can be fixed with either a large central or 3 peripheral small pegs.48
A large single peg is easier to implant and resistant to breakage. The 3 peripheral pegs provide better resistance against shear stresses, less interference with intraosseous blood supply and reduced patellar fracture risk. However, there are increased chances of peg breakage and subsequent implant loosening.77
The first generation metal backed patellar onlay components had problems such as metallosis due to excessive polyethylene wear and significant particulate debris generation.78
The congruent contact metal backed patellar prosthesis with rotating bearing used in the low contact stress knee arthroplasty have shown better results. The presumed advantages of this design are improved patellofemoral tracking, low contact stresses and low wear of the congruent polyethylene surface. In this system an anatomic polyethylene implant rotates freely on polished base plate which is fully porous coated on its back. However it is technically demanding to implant and also causes loss of significant patellar bone stock during the preparation.79
13
 
Conclusion
Total knee arthroplasty has evolved over the years into a successful surgery. This can be attributed to a better knowledge of the biomechanical principles, development of better prosthetic materials and refinement in the surgical technique over the years. Apart from the knowledge of design principles accurate and reproducible surgical technique still remains one of the most critical factors for a successful knee replacement surgery.
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