Revision total knee arthroplasty with the Total Condylar III system: A comparative analysis of 71 consecutive cases of osteoarthritis or inflammatory arthritis

Background?As revision total knee arthroplasty surgery is becoming more common, it is necessary to evaluate how individual revision prosthesis systems perform in degenerative and inflammatory arthritides. In this study, results of the use of the Total Condylar III (TC III) system in osteoarthritis (55 knees) were compared to results of its use in inflammatory arthritis (16).

Methods?Patients were followed radiographically for 5.9 (3.0–10.2) years and clinically for 3.0 (0.2–6.8) years, using re-revision as the endpoint.

Results?At 1 year after revision and at final follow-up, the total Knee Society knee score, function score and range of motion had improved (p?<?0.001) with no differences between osteoarthritis and inflammatory arthritis. No knee had definite component loosening, although 23 knees had asymptomatic radiolucent lines. Complications comprised 4 infections, 1 patellar pain syndrome and 1 rupture of the patellar tendon. Using any re-revi-sion of the prosthesis as the endpoint, 5-year survival was 95% and 8-year survival was 94%.

Interpretation?Concentration of demanding revision knee arthroplasties to a few hands led to good or excellent knee joint knee score results in four-fifths of the patients, and showed good outcome with the TCIII system. In spite of ligamentous laxity, propensity to develop infections, bone destruction and poor general health, patients with inflammatory arthritis had results similar to those with osteoarthritis.     

Revision total knee arthroplasty with the Total Condylar III system in inflammatory arthritis

We report a consecutive series of 16 revision total knee arthroplasties using the Total Condylar III system in 14 patients with inflammatory arthritis which were performed between 1994 and 2000. There were 11 women and three men with a mean age of 59 years (36 to 78). The patients were followed up for 74 months (44 to 122). The mean pre-operative Knee Society score of 37 points (0 to 77) improved to 88 (61 to 100) at follow-up (t-test, p < 0.001) indicating very good overall results. The mean range of flexion improved from 62 degrees (0 degrees to 120 degrees) to 98 degrees (0 degrees to 145 degrees) (t-test, p < 0.05) allowing the patients to stand from a sitting position. The mean Knee Society pain score improved from 22 (10 to 45) to 44 (20 to 50) (t-test, p < 0.05). No knee had definite loosening, although five showed asymptomatic radiolucent lines. Complications were seen in three cases, comprising patellar pain, patellar fracture and infection. These results suggest that the Total Condylar III system can be used successfully in revision total knee arthroplasty in inflammatory arthritis.     

Revision total knee arthroplasty using the total condylar III prosthesis

Implant selection for the severely damaged knee being treated by revision is difficult. Fixed or rotating hinges have provided mixed results with a high frequency of complication. An alternative to a hinge implant is the total condylar III prosthesis, which can substitute for a deficient collateral ligament. Between August 1980 and April 1987 total condylar III prostheses were used for revision of failed total knee arthroplasties (TKA) of 21 knees in 19 patients. In the same time interval, 649 TKA revisions were performed for a frequency of 3.2% using this prosthesis. The indications for using this prosthesis were bone loss in 10 knees, instability in 9 knees, supracondylar femur fracture in 1 knee, and implant malposition in one knee. At a 4-year follow-up evaluation the knee scores were excellent in 25%, good in 25%, fair in 25%, and poor in 25%. Complications occurred in 33% of the knees. The total condylar III prosthesis provided results similar to other constrained implants used for revision in patients with severe bone loss and ligamentous instability.     

骨性关节炎和炎症性关节炎行全膝关节置换翻修术临床效果的比较及相关分析

目的对应用单一翻修假体系统行膝关节置换翻修术的骨性关节炎与炎症性关节炎的临床材料进行汇总分析、对比。方法1994至2000年间,共69例患者71膝在芬兰坦配雷大学医学院医院应用翻修假体TCⅢ行全膝关节置换翻修术。56膝为女性,16膝为男性,平均年龄69．1岁（36～85岁）,平均随访时间为5.9年（3．0—10．2年）;16膝为炎症性关节炎,55膝为骨性关节炎,初次手术和翻修术的时间间隔平均为6．8年。临床评估参照KSS评分系统,再次翻修、截肢和死亡视为随访终止。结果所有患者术后1年和最终随访时的膝关节总评分、功能评分、活动范围、疼痛评分、行走评分及上楼评分等与术前相比差异有统计学意义（P〈0．001）。尽管23例假体周围有无症状性骨吸收线,但是关节均无明显结构上的松脱。并发症包括4例术后感染,1例髌骨疼痛综合症,1例髌腱断裂。以再次翻修作为终点,假体5年生存率为95％,8年生存率为94％。最终随访时,骨性关节炎患者的各项数据比炎症性关节炎患者稍好,但统计学分析结果示两组之间的差异无统计学意义。结论尽管炎症性关节炎会导致患者韧带松弛,容易感染,骨质破坏,一般情况较差,但是其行全膝关节置换翻修术的疗效与骨关节炎相接近。     

Total knee arthroplasty using the total condylar III knee prosthesis

Twenty-seven total knee arthroplasties (TKAs) were performed in 24 patients using the total condylar III knee prosthesis (TCP III) and were evaluated clinically and radiographically with a mean follow-up period of 4 years. Eighteen were revision TKAs, and nine were primary knee arthroplasties. Evaluations were made using the Hospital for Special Surgery (HSS) knee scale as well as the Knee Society radiographic evaluation method. Clinical results for all knees were 11% (3 of 27) excellent, 70% (19 of 27) good, 15% (4 of 27) fair, and 4% (1 of 27) poor. The one poor rating resulted from an intraoperative vascular injury. The results showed no statistical difference between revision and primary TKA. After operation, pain relief, range of motion, walking, function, and activity level improved in both the primary and revision patients. Radiolucencies 2 mm or greater in width were found in 6 of the 27 tibial components, in none of the 27 femoral components, and in 1 of the 19 patellar components. Only two tibial implants showed progressive radiolucencies. No correlation was found between the radiographic position of the implants and the clinical results. The authors conclude that the TCP III is a satisfactory choice for TKA in selected knees in which there is significant instability and in which intramedullary fixation is required.     

Clinical and radiographic results of the total condylar III and constrained condylar total knee arthroplasty

The Total Condylar III (Johnson and Johnson, Braintree, MA) and Constrained Condylar (Zimmer, Warsaw, IN) knee prostheses are nonlinked, semi-constrained prosthetic alternatives to rigid or rotating hinge prostheses for use in complex knee reconstructions. Forty-six Total Condylar III or Constrained Condylar prostheses were implanted with cement in 36 patients and followed for a mean of 5 years (range, 2–9 years). There were 25 primary total knee arthroplasties and 21 revision total knee arthroplasties. The knees were evaluated using The Hospital for Special Surgery 100-point knee rating system. Overall, 40 knees (87%) had a good or excellent clinical result, 2 knees (4%) had a fair result, and 4 knees (9%) had a poor result. There was one revision for loosening of a cemented, nonmodular Constrained Condylar prosthesis, and one knee had a debridement for a late, metastatic infection, but the components were retained. There were no mechanical failures in those knees that were primary arthroplasties, but two mechanical failures occurred in those knees that were revision arthroplasties. Radiographic review showed one asymptomatic loosening of a Constrained Condylar tibial component with an uncemented press-fit stem, and only 8 knees had scattered nonprogressive tibial bone—cement radiolucent lines. The Total Condylar III and Constrained Condylar semiconstrained prostheses are successful when used in complex knee reconstructions.     

Revision of the Gunston polycentric knee arthroplasty with total knee arthroplasty

The Gunston polycentric knee arthroplasty, first designed and performed by Frank Gunston in 1971, is the first prosthesis considering the natural knee biomechanics. Although the polycentric knee arthroplasty showed encouraging results to relieve pain and to preserve the preoperative range of motion and joint instability, the improvements in prosthesis design and arthroplasty technology rapidly made the polycentric knee prosthesis obsolete. Herein, we report a 58-year old male patient who had revision of the Gunston polycentric knee arthroplasty with total knee arthroplasty performed 32 years after the initial operation.     

Long-term results of total condylar knee arthroplasty in rheumatoid arthritis.

We have reviewed at an average period of ten years the results of 71 consecutive primary arthroplasties with the Insall-Burstein total condylar knee prosthesis in patients with rheumatoid arthritis. Their mean age at surgery was 52 years (24 to 72). At follow-up the overall results (Hospital for Special Surgery knee rating score) were excellent or good in 77%, fair in 11% and poor in 11%. There was residual pain in only 5% of patients with prostheses in situ; 58% could walk more than 500 m, and the median range of motion was 108 degrees. Eight knees had been revised. Five underwent arthrodesis because of deep infection and three needed revision arthroplasty for mechanical loosening. The crude survival rate of the arthroplasties was 89%. The presence of radiolucency around the tibial component correlated significantly with the severity of residual pain.     

Results of total knee arthroplasty using the posterior stabilized condylar prosthesis. A report of 137 consecutive cases

One hundred thirty-seven consecutive posterior stabilized total knee arthroplasties (TKAs) were reviewed. Average age of the patient was 61.1 years and length of postoperative follow-up period was 29.2 months. Patients were evaluated using the Hospital for Special Surgery (HSS) knee rating scores. Average preoperative scores improved from 52 to 92, postoperatively. Ninety-eight percent of patients had no pain or mild occasional pain postoperatively compared with 99% of patients experiencing severe to disabling pain preoperatively. Complications included one myocardial infarction, two deep venous thrombosis, one urinary tract infection, one patellar dislocation, and four wound problems. There were two incidences of seroma, one hematoma, and one deep infection requiring revision after joint debridement and systemic antibiotics. Also noted was one incidence of ligamentous laxity and one patella fracture.     

The total condylar knee prosthesis: a review of 71 operations

Seventy-one operations are reviewed, in which knees were replaced with the total condylar prosthesis. The follow-up period ranged between 1 and 7 years, with an average of 3.25 years. Osteoarthritis was diagnosed preoperatively in 53 knees and rheumatoid arthritis in 18. The results obtained in cases of osteoarthritis were better than those in cases of rheumatoid arthritis. The prognosis was adversely affected by obesity, preoperative flexion contracture of 30 degrees or more, wound-healing problems, wound infection, and postoperative manipulation under general anesthesia. The overall results were excellent in 48% of cases (34 knees), good in 28% (20 knees), fair in 11.3% (eight knees), and poor in 4.3% (three knees). Failure was experienced in 8.4% of cases (six knees).     

A functional and radiographic analysis of the total condylar knee arthroplasty

Twenty-one knees in 14 patients were studied during walking, in clinical follow-up, and radiographically. The purpose was to examine the relationship between dynamic loading at the knee joint during level walking in the early postoperative period (1-2 years) and longer-term (4 years) prosthetic performance. Joint kinematics and kinetics were measured while patients were walking in the laboratory. The results were compared with an age-matched control group of healthy normal subjects. Patients were analyzed when grouped according to original diagnoses of rheumatoid or osteoarthritis. After total knee arthroplasty, patients with rheumatoid arthritis walked with a significantly lower magnitude peak adduction moment (force tending to thrust the knee into varus) about the knee than patients with osteoarthritis. The osteoarthritic group had an increased varus axial alignment when compared to the rheumatoid group. There was a strong correlation between postoperative varus alignment and the magnitude of the adduction moment. These results suggest that dynamic loading at the knee is greatly affected by static alignment of the joints in patients with total knee arthroplasty. In spite of the lower adduction moment during level walking and its associated effects on lower compressive loads at the knee, the patients with rheumatoid arthritis had a significantly higher radiolucency index. Thus, it appears that quality of bone stock may be a more important factor in determining prosthetic loosening than dynamic loading at the knee joint following total knee arthroplasty.     

Revision total knee arthroplasty: fixation with modular stems

The number of revision total knee replacements continues to increase annually. To date, much of the literature has focused on the performance of titanium revision systems. The primary aim of the current study was to review the mid term results of a contemporary revision knee system, with alternative design features. Ninety-one consecutive patients having aseptic revision total knee arthroplasty with one, modular all-cobalt chrome stemmed revision knee system using hybrid stem fixation were studied prospectively. Eighty-nine revisions in 84 patients were reviewed at a mean of 5.9 years (range, 4.1-8.6 years). Significant improvements in pain scores (15 +/- 14 to 38 +/- 14), function (40 +/- 24 to 53 +/- 29), range of motion (88 degrees +/- 23 degrees to 98 degrees +/- 18 degrees ), and total Knee Society score (85 +/- 40 to 132 +/- 40) were seen at followup. Five patients had revision surgery, with a Kaplan-Meier survivorship of 93.5% at 8.6 years. Intermediate results support the use of cobalt chrome components and hybrid cement fixation; however, this fixation in combination with high articular constraint requires continued monitoring.     

Survivorship analysis of cemented total condylar knee arthroplasty: A long-term follow-up report on 348 cases

Survivorship analysis was used in the evaluation of 348 consecutive primary total condylar knee arthroplasties (total knee arthroplasties) performed on 253 patients in a 27-month period, with a maximum follow-up period of 12 years. The diagnosis was osteoarthrosis in 184 cases and rheumatoid arthritis in 164 cases. Ten patients (10 total knee arthroplasties) were lost to follow-up evaluation. The endpoint was defined as prosthesis not in situ. The variables considered were age, sex, body mass index, and diagnosis. The overall cumulative survival rate was 92%. The survival rate of the osteoarthrosis group was significantly higher (97%) than that of the rheumatoid arthritis group (87%). None of the other variables affected survival rate significantly.     

膝表面置换术在类风湿性膝关节炎和骨性膝关节炎的应用和比较

目的探讨膝关节表面置换术治疗类膝关节风湿性关节炎(RA)和膝关节骨性关节炎(OA)的临床疗效、安全性差异。方法自2010-01—2012-04采用膝关节表面置换术治疗68例(84膝)膝关节疾患,按照疾病类型分为OA组和RA组,对比分析2组手术时间、术中出血量、VAS评分、切口愈合时间、HSS单项评分及总分等。结果术后68例(84膝)获得平均47个月随访,随访期间无人工膝关节假体脱位。OA组手术时间、术中失血量、术后引流量及VAS评分显著低于RA组,差异有统计学意义(P0.05)。OA组术后1个月疼痛和HSS总分显著高于RA组,差异有统计学意义(P0.05),OA组术后1年和3年疼痛、功能、活动范围单项评分和HSS总分均显著高于RA组,差异有统计学意义(P0.05)。结论OA及RA人工全膝置换术后功能均有一定改善,与OA相比,RA患者术后近中期疗效相对较差,但远期疗效差异有待进一步研究。     

Revision of the stiff total knee arthroplasty

This study evaluated the improvement in range of motion after revision total knee arthroplasty (TKA) in a consecutive series of patients with TKAs presenting with pain and limited range of motion. Eleven stiff (range of motion <70 degrees ) and painful TKAs were revised with a posterior stabilized condylar prosthesis and reviewed after an average of 37.6 months (range, 24-53 months). The average range of motion increased from 39.7 degrees preoperatively to 83.2 degrees postoperatively. The mean flexion contracture decreased from 13.2 degrees to 0.9 degrees. Pain scores improved from 4.5 to 44.1, and all 11 patients were satisfied. This study shows that knee range of motion can improve significantly after revision TKA.     

Revision of the Sheehan total knee arthroplasty

The use of the Sheehan knee prosthesis extended from 1971 to 2002. It incorporated a semi-constrained hinge with intra-medullary stems cemented into the femur and tibia. While some authors have reported excellent short-term results, others have reported revision rates of up to 31% at 5–10 years. The aim of this study was to review the senior authors experience in revising these arthroplasties. We review 54 Sheehan total knee replacements and discuss the difficulties encountered during first and subsequent revisions and the often-complex reconstruction techniques used to overcome these.

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Résumé Lutilisation de la prothèse de genou de type Sheehan sest étendue de 1971 à 2002. Elle comportait une charnière semi-contrainte avec des tiges intra-médullaires cimentées dans le fémur et le tibia. Tandis que dexcellents résultats à court terme ont été rapportés par quelques auteurs, un taux de révision jusquà 31% à 5–10 ans a été rapporté par dautres. Le but de cette étude était examiner lexpérience de lauteur senior dans la révision des prothèses de Sheehan. Nous avons examiné 54 prothèses et discutons les difficultés rencontrées pendant larthroplastie initiale et les révisions ultérieures ainsi que les techniques souvent complexes de reconstruction utilisées pour les mener à bien.

     

Revision of a failed patellofemoral arthroplasty to a total knee arthroplasty

BACKGROUND: Patellofemoral arthroplasty is an effective treatment for isolated arthritis of the anterior compartment of the knee, but it is unclear whether it compromises the results of total knee arthroplasty if revision is necessary. The purpose of this study was to review the results of total knee arthroplasty after a prior patellofemoral arthroplasty. METHODS: Twelve failed patellofemoral replacements in ten patients were revised to total knee arthroplasties for isolated progressive tibiofemoral arthritis (six knees), isolated patellofemoral catching and maltracking (three), or a combination of both (three). Revisions were performed at a mean of four years after the patellofemoral arthroplasty. A posterior stabilized implant was used in each knee, without a need for stems, augments, or structural bone graft. Patients were assessed by clinical and radiographic follow-up, including Knee Society clinical and functional scores. Baseline preoperative Knee Society scores were obtained at the time of evaluation of the failed patellofemoral arthroplasty. RESULTS: At a mean follow-up of 3.1 years, the mean Knee Society clinical and functional scores had increased from 57 points preoperatively to 96 points and from 51 points preoperatively to 91 points, respectively. At the most recent follow-up, there was no clinical or radiographic evidence of patellofemoral maltracking, loosening, or wear. CONCLUSIONS: On the basis of our experience in this relatively small series with short-term follow-up, the results of total knee arthroplasty do not seem to be compromised after revision of the failed patellofemoral replacement.     

膝关节骨关节炎患者初次全膝关节置换术中选择髌骨置换的Meta分析

目的探讨膝关节骨关节炎(OA)进行初次全膝关节置换术(TKA)中选择髌骨置换与否的疗效,评价两种不同治疗选择的差异。方法检索Medline、Embase、Cochranelibrary、CBM,收集膝关节OA行初次TKA术中髌骨置换与否的临床对照试验,提取数据分析,采用RevMan5.0.18进行Meta分析。结果纳入8个前瞻性随机对照试验,共822例手术,其中髌骨置换组373例,髌骨非置换组444例。髌骨置换与非置换组比较,前膝痛与KSS评分均无明显的统计学意义(P0.5),置换组的因髌股关节问题而再次手术率低于非置换组[RR=0.53,95%CI(0.29,0.96),P=0.04],但置换组再次手术的原因除了常见的前膝痛,还包括髌骨假体相关的并发症。结论膝关节OA的患者行初次TKA术中选择髌骨置换与否的前膝痛与KSS评分无明显的统计学意义,置换组的因髌股关节问题再次手术率低于非置换组,但置换组再次手术的复杂性大于非置换组。