Total knee arthroplasty with retention of both cruciate ligaments. A nine to eleven-year follow-up study.

BACKGROUND: Although many early designs of total knee arthroplasty allowed the retention of both cruciate ligaments, in most current designs of knee replacement systems, either both cruciate ligaments are removed or the posterior cruciate ligament alone is retained. This report is a review of a series of total knee arthroplasties in which both cruciate ligaments were retained. METHODS: The results of 163 total knee arthroplasties (130 patients) in which both cruciate ligaments were retained were assessed prospectively. One hundred and seven knees (eighty-nine patients) were followed for an average of ten years. There were thirty-four men and ninety-six women, and the average age at the time of the index arthroplasty was sixty-seven years (range, forty-two to eighty-four years). The diagnosis was osteoarthritis in 122 (75 percent) of the knees and rheumatoid arthritis in forty-one (25 percent). Twenty-six knees had a valgus deformity, 109 had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus. The anterior cruciate ligament was relatively normal in ninety-six knees and was partly degenerated in sixty-seven knees. With use of the rating system of the Knee Society, all 163 knees were prospectively evaluated at yearly intervals; fifty-six of these knees (in forty-one patients) were followed in this manner until the patient died or was lost to follow-up. RESULTS: One hundred and four (97 percent) of the 107 knees available for study at an average of ten years had an excellent or good result. At the time of the latest follow-up, pain was adequately relieved in ninety-seven knees (91 percent) and the average range of flexion was 107+/-12.6 degrees (range, 65 to 135 degrees). Ninety-five knees (89 percent) had normal anteroposterior stability (less than five millimeters of movement in this plane), and twelve knees (11 percent) had five to ten millimeters of movement as demonstrated by the drawer sign. Ninety-six knees (90 percent) had normal mediolateral stability, and eleven (10 percent) had 5 to 10 degrees of laxity. Ninety-four knees (88 percent) had valgus alignment of 5 to 10 degrees. The average knee score was 91+/-8.4 points (range, 54 to 100 points), and the average functional score was 82+/-21 (range, 10 to 100 points). The survival rate at ten years, with revision as the end point, was 95+/-2.0 percent. Seven (4 percent) of the 163 knees in this series were revised. There were no revisions for patellar problems or aseptic loosening of the tibial component. CONCLUSIONS: The good anteroposterior stability in this series after an average follow-up period of ten years indicates that both the anterior and the posterior cruciate ligaments, even when partly degenerated, remain functional when they are preserved in a total knee arthroplasty.     

Instability after anterior cruciate ligament rupture. Measurements of sagittal laxity compared in 11 cases.

Manual tests and 2 external devices were used together with roentgen stereophotogrammetry (RSA) and an active weight-bearing radiographic method to measure the sagittal laxity in 11 knees with anterior-cruciate-ligament rupture. In 5 knees no ligament surgery had been performed (unstable knees) and in 6 knees a reconstruction had been performed one year before the examination (stable knees). There were positive correlations between all methods, including the manual tests when all knees, both stable and unstable, were analyzed together. However, the mean values of the total displacement differed between the methods, especially when comparing the weight-bearing radiographs with the three other methods. Some knees with substantial displacement during passive loading did not show any displacement when weight bearing; the measurements thus depended on both the ligamentous laxity and the patient's neuromuscular control of the joint. When the stable knees were analyzed separately, higher mean values were recorded with the external devices than with RSA using 180 N load. This could be explained by an error from soft tissue deformation which added to the skeletal displacement when the external devices were used.     

Suture of the torn anterior cruciate ligament. 5-year follow-up of 60 cases using an instrumental stability test.

60 patients were examined 5 (2-9) years after simple suture of acute rupture of the anterior cruciate ligament. In the follow-up the patients were examined clinically and by instrumental testing of stability (Acufex Knee Signature System). 10 knees had had a ligament reconstruction during the follow-up period, 28 knees were stable, and 22 unstable. By the Lysholm knee-score, function was rated excellent or good in both stable and unstable knees and the Tegner activity score dropped insignificantly. A positive correlation was found between the measured laxity and the clinical tests. Instrumental stability testing seems to be a reliable supplementary tool in the diagnosis of anterior cruciate ligament insufficiency. Ligament repair by simple suture was not better than reported results on conservative treatment.     

Total knee arthroplasty with retention of both cruciate ligaments. A 9 to 11 year follow-up study

This is a prospective assessment of 163 total knee arthroplasties in 130 patients with the retention of both cruciate ligaments of which 107 knees in 89 patients have been followed for ten years. The patients were 34 men and 96 women whose average age, at the time of the index arthroplasty, was 67 years (range: 40 to 84 years). The diagnosis was osteoarthritis in 122 (75%) knees and rheumatoid arthritis in 41 (25%). Twenty-six knees had a valgus deformity, 109 knees a varus deformity and 28 knees had a normal alignment of 5 to 10° of valgus. The anterior cruciate ligament was relatively normal in 96 knees and partly degenerated in 67 knees. Using the Knee Society rating system (37), all 163 knees were prospectively evaluated at yearly intervals including 56 knees in 41 patients who were followed in this manner until they died or were lost to follow-up. 104 knees (97%) of the 107 knees available for study at ten years had excellent or good results. At the latest follow-up in this group of patients, pain was adequately relieved in 97 knees (91%), the average flexion range was 107 ± 12.6° (range: 65 to 135°). Ninety-five knees (89%) had normal antero-posterior stability (less than 5 mm) and 12 knees (11%) had (5 to 10 mm) as determined by the drawer sign. Ninety-six knees (90%) had normal mediolateral stability and 11 knees (10%) had a laxity from 5 to 10°. Ninety-four knees (88%) had a valgus alignment of 5 to 10°. The average knee score was 90.7 ± 8.4 (range: 54 to 100) and the functional score was 82 ± 21 (range: 10 to 100). The survival at ten years with the end point being revision was 94.8% ± 1.95. Seven knees (4.3%) of the 163 knees in this series were revised. There were no revision for patellar problems or aseptic tibial component loosening. The good anteroposterior stability at latest follow-up in this series indicates that both the anterior and posterior cruciate ligaments, even when partly degenerated, remain functional after an average follow-up of ten years.     

Arthroplasty of both hips and both knees in rheumatoid arthritis.

Eleven patients with rheumatoid arthritis underwent total joint replacement of both hips and both knees (four-joint arthroplasty). All patients had increased function and decreased pain. Severe rheumatoid arthritis in both hips and knees does not preclude a satisfactory result after replacement arthroplasty.     

The articular cartilage after osteotomy for medial gonarthrosis. Biopsies after 2 years in 19 cases.

In 19 consecutive patients with medial gonarthrosis, an arthroscopic examination with a biopsy of the load-bearing cartilage in the medial femoral condyle was undertaken at the same time as a proximal tibial osteotomy. A follow-up arthroscopic biopsy was performed on an average of 2 years after the osteotomy. In 9 knees there was an improvement in the cartilage quality, 8 knees were unchanged, whereas 2 knees had deteriorated. Radiographically, 6 knees had improved, 11 were unchanged and 2 had deteriorated. We found no correlation between cartilage improvement and the clinical and radiographic outcome. Our results confirm that an osteotomy has a beneficial effect on the load-bearing cartilage in the medial femoral condyle.     

Radiographic assessment of instability of the knee due to rupture of the anterior cruciate ligament. A quadriceps-contraction technique

We compared the results of a radiographic technique for the measurement of instability of the knee with those obtained with a KT-1000 arthrometer. The study was conducted on both knees of sixty patients who had a ruptured anterior-cruciate ligament in one knee, as well as in ten control subjects. The radiographic technique included the examination of a true lateral radiograph, made while the knee was in full extension and the quadriceps was maximally contracted, with a 66.7-newton downward force produced by a 6.8-kilogram weight suspended from the ankle. As demonstrated by both techniques, the maximum difference between the displacements of the right and left knees in the control subjects was 2.5 millimeters and the mean difference between the displacements in the two knees in the patients was 7.5 millimeters. In fourteen of the sixty knees in which the ligament was ruptured, the injury was acute. The forward translation of the medial side in these fourteen knees was compared with that in the forty-six knees in which the injury was chronic. The mean difference in the displacement of the medial side in the right and left knees was 3.5 millimeters in the fourteen patients who had an acute injury and 5.0 millimeters in the forty-six patients who had a chronic injury. Thirteen of the sixty patients had disruption of the posteromedial corner of the injured knee, and the translation of the medial side in these knees was significantly increased compared with that in the intact knees of the same patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

A prospective cost analysis following operative treatment of unstable ankle fractures30 patients followed for 1 year

A middle-aged woman had had anterior poliomyelitis at 11 years of age that had left her with residual weakness in both legs. She gradually developed a recurvatum and valgus deformity in both knees, which caused pain and instability. A technique to restore the top of the tibia by means of a rotational osteotomy of the lateral tibial plateau is presented. This operation resulted in painless, asymptomatic knees and improved function.     

Debridement arthroscopy. 10-year followup.

The treatment of osteoarthritis of the knee is a difficult problem. In the senior author's opinion, nonaggressive arthroscopic debridement of the knee is an effective procedure to relieve pain and restore function in patients with osteoarthritis of the knee. A subjective telephone interview of patients done 10 or more years after arthroscopic debridement evaluated the long term results of this treatment in patients with osteoarthritis of the knee. The patients all were candidates for total knee replacement who selected arthroscopy as a temporizing procedure. Of the 191 knees in patients undergoing arthroscopic debridement, 77 patients (91 knees) were contacted for followup. Sixty-seven percent of the 91 knees did not have total knee arthroplasty at an average of 13.2 years followup. The Tegner activity score averaged 3.5 and patient satisfaction averaged 8.6 on a 0 to 10 scale. Twenty-one patients (30 knees) or (33%) had total knee arthroplasty at an average of 6.7 years. Seven of these had total knee arthroplasty within 2 years of arthroscopic debridement. Six of these seven knees had Outerbridge Grade 4 articular cartilage changes and clinically significant meniscus tears. Seven of the 19 knees (37%) with Outerbridge Grade 4 changes in 80% of one knee compartment did not require total knee arthroplasty after greater than 10 year followup. The difficulties in long term followup in this patient population is evident, yet the number of patients who had a functional lifestyle after arthroscopic debridement was notable.     

The Hauser operation for patellar dislocation. 3-32-year results in 63 knees

The Hauser operation for patellar dislocation was performed in 34 women and 20 men, median age 18 (3-55) years; one leg was amputated because of wound infection with chronic septic arthritis. At the time of follow-up, 8 (3-32) years after the operation 57 knees had normal or almost normal patellar stability, but only 26 knees were free from pain. Only 16 knees had both normal patellar stability and were without pain. Patellar arthrosis had developed in 16 knees and femorotibial arthrosis in 23 knees. Eleven patients operated on before the age of 15 years showed varying grades of axial deformity of the proximal tibia.     

A fresh appraisal of tibial osteotomy for osteoarthritis of the knee.

A retrospective study was performed on 189 arthritic knees treated by tibial osteotomy at the Nuffield Orthopaedic Centre, Oxford, England to determine the quality of the results. The objective results were deduced from a numerical system of grading of pain, function, and movement, for 132 osteoarthritic knees. No statistical difference was found between high and low tibial osteotomies. Varus and male knees fared better than valgus and female knees. The result was significant only for the male varus group. Correction of the angular deformity had a profound influence on the results for varus but not for valgus knees. A joint tilt increase usually occurred and was associated with increased subluxation and instability in valgus knees but decreased or unchanged subluxation in varus knees. This was held to be an important cause of failure to achieve good results in valgus knees, and appeared to be an irremedial fault of tibial osteotomy.     

Subchondral bone strength in arthrosis. Cadaver studies of tibial condyles

We measured the axial penetration strength of subchondral cancellous bone in a close, regular pattern at the tibial resection surface of five valgus and seven varus human, cadaveric knees. The strength patterns obtained were illustrated by pseudo-three-dimensional reconstructions of strength values as a function of the location on the resection surface. The varus knees had high strength values towards the medial margin of the medial condyle. Three qualitatively different strength patterns were distinguished in the valgus knees: two knees showed a near normal strength distribution with higher peak values medially; two knees with centrolateral bony attrition had high bone strength values at the center of the lateral condyle; and one knee with moderate posterolateral bony attrition showed a high strength area at the posterolateral aspect of the lateral condyle. In both types of malalignment, there was a decrease of bone strength with the depth from the resection surface.     

Congenital discoid lateral meniscus in children. A follow-up study and evolution of management

Fifty-two children with 62 discoid lateral menisci were reviewed at an average follow-up of 5.5 years. Their average age at operation was 10.5 years and the mean delay in diagnosis was 24 months. Most of the children had vague and intermittent symptoms and the classical clunk was demonstrable in only 39% of the knees. An associated osteochondritis dissecans of the lateral femoral condyle was seen in seven knees. Forty-eight knees with symptomatic torn discoid menisci underwent open total lateral meniscectomy, six had arthroscopic partial meniscectomy and eight knees with intact discoid menisci, were left alone. Based on Ikeuchi's grading (Ikeuchi 1982), 37% of the knees had an excellent result, 47% had a good result and 16% had a fair result: none was poor. Arthroscopic partial meniscectomy is recommended only when the posterior attachment of the discoid meniscus is stable. A total meniscectomy is indicated for the Wrisberg-ligament type of discoid meniscus with posterior instability.     

Lateral release rates after total knee arthroplasty.

For a total knee replacement to function well, the patella must track centrally in the trochlear groove. A lateral release may be required to ensure such central tracking. During surgery, an evaluation was made of patellar tracking in 178 patients undergoing total knee replacement. The Genesis II prosthesis with a deep-dish tibial insert was used for all the patients. The evaluation was made using the nontouch technique and the axial traction (modified no-touch) technique before and after release of the tourniquet. With the tourniquet still inflated, there were 29 knees in which the patella tilted laterally and 11 additional knees in which the patella subluxed laterally. Using the modified no-touch technique, there were only 12 knees in which the patella tilted laterally and five in which it subluxed laterally. With the tourniquet deflated, only nine of the patellas tilted laterally and three subluxed laterally. It was only in this final group that a lateral release was done for an overall lateral release rate of 6%. Eleven of these 12 knees had a preoperative fixed valgus deformity greater than 10 degrees. Only one lateral release was required for a patient with a preoperative varus deformity. Four patients with a preoperative fixed valgus deformity and a laterally subluxed patella did not require a lateral release. Axial realignment and reconstitution of an anterior trochlear surface by the implant were sufficient to centralize the patella. Had only the no-touch test been used, there would have been 18 unnecessary lateral releases done. When the knees were evaluated radiographically, there was no statistical difference in patellar position between that group and the knees that required a lateral release. Overall in the entire group at 6 weeks after surgery, 105 knees (59%) had no patellar tilt. At 3 months, as quadriceps tone returned to normal, 138 knees (79%) had no patellar tilt. Thirty-three of the remaining 35 knees had a patellar tilt less than 10 degrees. None of the patients had lateral patellar subluxation at any time after surgery.     

Congenital contractural arachnodactyly. Report of a case and of an operation for knee contracture

A patient with typical congenital contractural arachnodactyly followed up from the age of 12 years to the age of 48 is reported. He had spiderlike fingers and toes and marked contractures of the knees, ankles, toes, shoulders, elbows and fingers; the mobility of the hips and wrists was almost normal. Persistent knee contractures prevented him from walking. In his twenties he had an osteotomy of both femora and shortening of the patellar tendons which enabled him to walk for the first time in an upright position without external support. When seen at the age of 48 the range of movement of his knees was 0 to 90 degrees. He was working as a turner and had been doing so for almost 20 years.     

Prognosis for patients with medial gonarthrosis. A 16-year follow-up study of 189 knees

All 189 knees (157 patients) that had had primary medial compartment arthrosis in 1972 were followed until 1988. After 14 years, tibial osteotomy had been performed in 85 knees and arthroplasty in 33 knees. No major surgery had been performed in 71 knees; of these 71 knees, 31 patients (40 knees) had died. Of the remaining 23 patients (31 knees), the majority had an unsatisfactory knee and managed only on a low activity level. In 20 of 24 knees, progress of the arthrosis was recorded roentgenographically. Because natural course of medial gonarthrosis has a poor prognosis, the majority of patients suffering from this condition will eventually have major knee surgery.     

Should the patella be replaced in total knee replacement?

In 170 total knee arthroplasties for osteoarthritis 71 did not receive a patellar replacement (group A), while 99 knees had a cemented polyethylene patella (group B). The mean follow-up time was 36 months (30-50 months). In group A 10 patients underwent second-stage patellar resurfacing and in group B 2 knees underwent revision of the patellar component. Radiologically the average patellar congruency was similar. In both groups there were 21 non-congruent knees. In group A 8 were symptomatic and had low scores compared to 2 in group B (P<0.05). The mean HSS score and patellar score were higher in group B than in group A (P<0.05).     

Polyethylene wear of the PCA unicompartmental knee. Prospective 5 (4-8) year study of 120 arthrosis knees.

In Lund, 120 arthrosis knees had the PCA unicompartmental endoprosthesis during 1983-1987 and were followed prospectively for 5 (4-8) years. 17 knees were excluded from the final clinical follow-up because of the development of rheumatoid arthritis (2), severe neurologic disease (3), or death (12). Subjectively, 68 knees were much improved, 26 improved and 9 had failed. First-steps problems were only present in the uncemented group of 49 knees. Of the 9 failures (7 cemented and 2 uncemented) 6 were revised. The main reason for revision was loosening of the femoral component (2), tibial component (2), or both components (1), and polyethylene wear (1). However, all revised tibial components showed polyethylene wear, in 4 quite pronounced. Weight-bearing radiographs (61 knees) revealed major polyethylene wear in an additional 14 knees; not only in thin tibial components. There may be an increasing clinical problem due to polyethylene wear. With the presented findings the PCA unicompartmental knee endoprosthesis cannot be recommended.     

Posterior stabilized prosthesis. Results after follow-up of nine to twelve years.

We reviewed, nine to twelve years postoperatively, the records on an original cohort of 289 arthroplasties (218 patients) in which a posterior stabilized knee prosthesis with an all-polyethylene tibial component had been inserted at The Hospital for Special Surgery. One hundred and eighty intact prostheses in 139 patients were available for this analysis. Fourteen knees in fourteen patients had had a revision procedure. Five of these fourteen patients had had a bilateral arthroplasty, but only one knee of each of the five patients had been revised. Forty-eight of the patients (sixty-six knees) had died less than nine years after the operation. Twenty-nine other knees (twenty-two patients) had been lost to follow-up before a nine-year evaluation could be performed. Considering all 194 knees (including the fourteen that had been revised), the result with the system of The Hospital for Special Surgery was excellent for 117 knees (61 per cent), good for fifty-one (26 per cent), fair for twelve (6 per cent), and poor for the fourteen knees (7 per cent) that had been revised. The 180 knees in which the prosthesis was intact were also rated with the new scoring system of The Knee Society: the average postoperative knee score was 92 points (range, 35 to 100 points), and the average score for function was 66 points (range, 0 to 100 points). Survivorship analysis showed that the average annual rate of failure was 0.4 per cent and that the over-all rate of success at thirteen years was 94 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Unicompartmental knee replacement: a comparison of constrained and unconstrained designs.

Seventy-six patients who had eighty-seven unicompartmental knee replacements were followed for an average of fifty-three months (range, two to twelve years). The operation was on the medial side in eighty-two knees and on the lateral side in five. Fifty replacements were unconstrained and thirty-seven were constrained. Of the fifty knees that had an unconstrained replacement, forty-nine (98 per cent) had a good or excellent result, compared with only twenty-six (70 per cent) of the knees that had a constrained replacement; the difference is significant (p = 0.0007). No knee that had an unconstrained replacement had a poor result, compared with nine (24 per cent) of the knees that had a constrained replacement (p = 0.0009). Four (8 per cent) of the fifty knees that had an unconstrained replacement later had a revision total knee arthroplasty, compared with ten (27 per cent) of the thirty-seven knees that had a constrained replacement; the difference is significant (p = 0.04). Noteworthy degenerative changes in the opposite compartment occurred in only one of the eighty-seven knees (a knee in which an unconstrained prosthesis had been inserted).