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-revision 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.     

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。     

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.     

Survival analysis of cemented Press-Fit Condylar total knee arthroplasty

We performed a survival analysis on 354 cemented primary Press-Fit Condylar (PFC) total knee arthroplasties (TKA) in 277 patients with prospective follow-up (mean, 6 years; range, 2-11.7 years). No patient was lost to follow-up. Using revision for all causes as the endpoint, the cumulative survival rate at 10 years was 95.5% (95% confidence interval, 90.1%-98.1%). The 10-year clinical outcome available on 41 patients was good, with significant improvement in pain and mobility assessments using the Nottingham data collection system. Our results indicate that the cemented PFC TKA has good long-term survival based on revision as the endpoint. Revision for implant failure is rare and brings to question modifications to this prosthesis.     

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.     

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.     

Revision total knee arthroplasty. A survival analysis.

The results of revision total knee arthroplasty (TKA) have been documented reasonably well in the literature. It is notable, however, that none of these reports have used the technique known as survival analysis to compare virgin and revision arthroplasties. This technique has an advantage over conventional analyses because it does not exclude patient data for inadequate follow-up study or patient death. In this study, survival analysis was applied to 37 revision TKAs performed exclusively by the senior author. With failure defined as removal of the prosthesis, revision surgeries experienced a 97.0% survival rate at 6 years. The secondary arthroplasty demonstrated a significantly lower survival rate than the index procedure over a period of approximately 6 years.     

Salvage of failed hinge knee arthroplasty with a Total Condylar III type prosthesis

Fourteen failed aseptic-hinge total-knee arthroplasties (TKA) were reviewed to determine if an unlinked metal to plastic Total Condylar III type prosthesis can be used for salvage procedure. The overall preoperative Hospital for Special Surgery knee-rating score was 58 and improved to 81 post-operatively. The average postrevision range of motion was 83 degrees. The soft tissue sleeve, the built-in constraint of the prosthesis, and the restoration of the bone deficiency provided good stability, despite the loss of the collateral and cruciate ligaments. Radiolucent lines, less than 1 mm in width and incomplete, appeared in four femoral and ten tibial bone-cement interfaces. In one femoral component there was a 2-mm radiolucency with a cement fracture at the femoral stem tip. There were no failures or repeated revisions, but two knees required postoperative manipulation to improve motion. Total Condylar III type prosthesis can be satisfactorily used to salvage failed hinge TKA.     

Clinical results of total knee revision using the Total Condylar III prosthesis

The clinical results after knee revision arthroplasty using the Total Condylar III (TC III) prosthesis were reviewed in 36 patients (36 knees). Patients were assessed by physical examination, completion of a 100-point, modified Hospital for Special Surgery knee rating form, and roentgenographic evaluation. There were 27 women and nine men, with a mean age of 68 years. Mean follow-up period was 45 months (range, 24-84 months). Reason for revision was sepsis in 15 patients and loosening or instability in 21 patients. Twenty were Category C patients with multiple joint involvement or significant medical infirmity. Preoperative knee scores ranged from 11-72 points (mean, 36 points). Postoperative scores ranged from 40-99 points (mean, 77 points). Clinical results were graded according to Insall. Eleven patients were graded excellent, 14 patients good, six fair, four poor, and there was one failure. Pain scores improved from a mean preoperative score of 16 points to 43 points postoperatively (50 points possible). However, function scores improved less dramatically. Range of motion based on maximum flexion averaged 98 degrees postoperatively. Varus tibial placement occurred in 50% (range, 1 degree-9 degrees). Slight flexion of the femur was seen in 73%. Lucent lines occurred in 60%, with 16% of the patients showing progressive tibial lucencies. The TC III prosthesis for revision arthroplasty is effective for salvaging unstable knees. Since the natural history of tibial radiolucency is not clear, less-constrained devices should probably be used when possible.     

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 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 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 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.     

一期全膝关节置换术治疗膝关节骨关节炎合并关节外畸形

 目的 探讨膝关节骨关节炎合并关节外畸形患者一期行全膝关节置换术(total knee arthroplasty,TKA)的可行性及其疗效。方法 2006年6月至2010年4月对9例骨关节炎合并关节外畸形患者行一期TKA.男 2例, 女7例;年龄 34~69岁,平均 51岁。股骨侧畸形5例.胫骨侧畸形4例;除 1例畸形由发育不良引起外.其余 8例均由骨折畸形愈合造成。结果 术后随访时间 7~54个月,平均 29个月。 HSS评分从术前平均 18.7分(6~39分).提高到术后平均 89.8分(81~96分)。膝关节活动度由术前平均 46.7°(0°~100°).提高到术后平均 100.6°(85°~115°)。下肢力线由术前平均偏移 11.8°(2°~21°)减少到术后平均偏移 1°(0°~4°);未发现假体松动征象。除 1例患者随访发现截骨处延迟愈合外.其余患者均无感染、下肢深静脉血栓、膝关节不稳及髌骨问题等并发症。结论虽然伴有关节外畸形的膝关节骨关节炎患者一期行 TKA手术难度较大.但通过制定合理的手术方案可以取得与普通 TKA相似的手术效果。如果可行.推荐采用关节内代偿性截骨加软组织平衡术矫正畸形。     

Total knee arthroplasty in diabetic patients: a study of 109 consecutive cases

The outcome of 109 consecutive total knee arthroplasties in 86 diabetic patients was studied. There were 73 women and 13 men, with a mean age of 69 years (range, 56-84 years). All the patients were followed for at least 36 months. The mean follow-up period was 42 months (range, 36-60 months). In the early postoperative period (< or =1 month), the overall wound infection rate was 7.3% (8 knees). The risk of deep joint infection was 5.5% (6 knees). Of the patients, 15% (17 knees) developed a urinary tract infection after the operation. The superficial and deep infection rates were higher when compared with a similar study in the general population. Maximum precautions should be taken for diabetic patients undergoing total knee arthroplasties.     

Cementless total knee arthroplasty in patients with inflammatory arthritis and compromised bone

Patients with bone compromised by inflammatory arthritis and medications are often excluded from cementless total knee arthroplasty (TKA) because of concerns regarding implant fixation and ingrowth. However, many such patients are young and at long-term risk for implant failure no matter what the fixation technique. Improved implant designs and technique may improve results. Cementless arthroplasty was performed in 45 patients with inflammatory arthritis. There were 38 patients with 53 implants available for follow-up evaluation during a 2- to 6.4-year period (average, 3.3 years). Medications included steroids (16 patients), nonsteroidal antiinflammatory drugs (36 patients), and cytotoxic agents (12 patients). Twenty-nine patients were using at least two types of medication. Prostheses included the Tricon P, Tricon M, Miller-Galante, and Anatomic Modular Knee (AMK) prosthesis. The procedures were performed using standard ligament-balancing techniques. Tibial resections were within 1 cm of the tibial plateau, thereby necessitating extensive bone grafts in ten patients. Tibial components were chosen for maximal cortical rim contact. Roentgenograms were reviewed for alignment, tibial rim contact, radiolucencies, gaps, sclerosis, and subsidence. Patients with no evidence of gap or lucency had spot films under image control. Hospital for Special Surgery knee scores averaged 47 preoperatively and 88 at follow-up examination. Alignment was from 3 degrees valgus to 9 degrees valgus (average, 6 degrees valgus), with a tibial axis of 0 degrees +/- 2 degrees. Plateau coverage was within 2.4 mm (average) of the cortical rim in all planes in the anteroposterior (AP) and lateral views. Tibial sclerosis occurred with equal frequency in all AP zones and was present equally in anterior and posterolateral zones. Gaps and lucencies were more common laterally. Fifteen femoral components showed a disturbing, localized osteopenia. Sclerosis, gap, and lucency were most common anteriorly. Cementless TKA with appropriate technique can produce results comparable to cemented surgery in patients with bone quality compromised by inflammatory arthritis, steroids, and nonsteroidal and cytotoxic agents. The femoral bone response suggests an intimate bone implant relationship. The tibia shows little direct coupling of prosthesis to bone. These responses are similar to reports from other studies. Fixation is sufficient to allow for continued analysis over time and results are encouraging.     

Midterm results of cemented Press Fit Condylar Sigma total knee arthroplasty system

PURPOSE: To evaluate the midterm results of 50 patients who underwent total knee replacement using Press Fit Condylar (PFC) Sigma system. METHODS: We retrospectively reviewed 87 consecutive cases (50 patients with 37 bilateral cases) of PFC Sigma total knee replacement performed between January 1998 and December 1999. Patients were evaluated clinically and radiographically by an independent observer. The American Knee Society Score, Oxford Knee Score, and Knee Society radiographic assessment were used to rate knee function and to determine the satisfaction level of each patient. RESULTS: The mean age of the patients at the time of operation was 65 years (range, 41-85 years). The mean follow-up period was 5.4 years (range, 4.5-6.4 years). 44 patients (79 knees) were available for follow-up, 3 patients (3 knees) were lost to follow-up, and 3 patients (5 knees) died of unrelated causes. At the final follow-up, the mean Oxford Knee Score was 22. Using the American Knee Society Score, 88% of the knees were rated excellent, 4% good, 2% fair, and 6% poor. Five knees required revision surgery, the indications being infection in 4 knees and aseptic loosening in one knee. The survival rate of the implants was 94% at 6 years. CONCLUSION: The PFC Sigma total knee arthroplasty system has demonstrated good midterm results at our institution.