The Genesis total knee prosthesis: a 10-year followup study.

This current author reports on the results of 100 consecutive patients with osteoarthritis who underwent a primary cemented total knee replacement using the Genesis prosthesis and who have been followed up for at least 10 years after surgery. In patients in whom the posterior cruciate ligament was sacrificed (combined flexion and angular deformities > 15 degrees to 20 degrees) a posterior-stabilized cam module was affixed to the femoral component and a posterior-stabilized polyethylene was used. More than 95% of patients in both groups had excellent pain relief. The mean flexion was 114 degrees in the group of patients in whom the posterior cruciate ligament was sacrificed and 117 degrees in the group of patients in whom the posterior cruciate ligament was retained. Partial bone cement tibial radiolucencies were seen in 12% of the patients in whom the posterior cruciate ligament was retained and 2% of the patients in whom the posterior cruciate ligament was sacrificed. At 10 years, 76% of the group in whom the posterior cruciate ligament was retained had excellent results and 20% had good results. In the group in whom the posterior cruciate ligament was sacrificed 75% had excellent results and 23% had good results. The survivorship was 96% in the group of patients in whom the posterior cruciate ligament was retained and 97% in the group of patients in whom the posterior cruciate ligament was sacrificed.     

A hydroxyapatite-coated Insall-Burstein II total knee replacement: 11-year results

We report the clinical and radiographic outcome of a consecutive series of 138 hydroxyapatite-coated total knee replacements with a mean follow-up of 11 years (10 to 13). The patients were entered into a prospective study and all living patients (76 knees) were evaluated. The Hospital for Special Surgery knee score was obtained for comparison with the pre-operative situation. No patient was lost to follow-up. Radiographic assessment revealed no loosening. Seven prostheses have been revised, giving a cumulative survival rate of 93% at 13 years. We believe this to be the longest follow-up report available for an hydroxyapatite-coated knee replacement and the first for this design of Insall-Burstein II knee.     

Insall-Burstein posterior-stabilized knee prosthesis in rheumatoid arthritis

The authors reviewed 65 Insall-Burstein (Zimmer, Warsaw, IN) total condylar posterior-stabilized knee prostheses in 50 patients with rheumatoid arthritis with a follow-up period of at least 5 years (range, 5–13 years). Forty-two knees in 31 patients were evaluated using the Knee Society knee and functional rating scores. Radiographic assessment was performed using standing long radiographs (hip to ankle). Radiolucent lines were studied using fluoroscopic-centered views. Excellent or good clinical results were obtained in 95% of the cases, and the average knee score improved from 22.5 to 90 points. No cases of radiologic loosening were observed. Incomplete radiolucent lines around the tibial component were detected in only 17% and were nonprogressive. Two patients developed hematogenous late deep infection, which required removal of the prosthesis in both, followed, at a second stage, by arthrodesis in one and prosthesis reimplantation in the other. Three knees (7%) had a painful impingement of the patella. Two of these were successfully reoperated with arthroscopic debridement of the peripatellar synovial tissues. Survivorship analysis, based on endpoints such as prosthesis removal for any cause or radiologic loosening (complete radiolucent line thicker than 1 mm, tilt, or subsidence of the component), showed a cumulative success rate of 96.2% at 13 years.     

Ten- to 14-year clinical followup of the cementless Natural Knee system.

Of 300 consecutive knees (238 patients) that had undergone arthroplasty with the cementless Natural Knee prosthesis from 1985 to 1989, 176 knees (141 patients) were available for followup at an average of 12 +/- 1 years after the operation. Knee function was improved significantly. Modified Hospital for Special Surgery knee scores improved from 59.1 +/- 13.2 points preoperatively to 97.8 +/- 4.7 points at last followup. At last followup, knee range of motion averaged 0 degrees +/- 2 degrees to 120 degrees +/- 10 degrees. Implant survival was 93.4% (including infection and simple polyethylene exchanges) and 95.1% (excluding infection and simple polyethylene exchanges) at 10 years when applying the Kaplan-Meier survival analysis, using loose components, revision, or both as failure criteria. Besides the three revisions for infection, only two femoral and one tibial component required revision. The patellar component survivorship at 10 years was 95.1%. All patellar revisions were attributed to edge wear. Subsequent operative and design changes, including patellar component medialization and countersinking, have decreased the incidence of patellar revision. The long-term results of this cementless knee system compare favorably with those of cemented systems. The Natural Knee design has provided excellent and predictable long-term clinical results in the current series of active patients.     

Ten- to 14-year results of a ceramic hip prosthesis.

One hundred total hip arthroplasties with a cementless aluminum oxide socket and ball with different types of cemented metal femoral stems were performed from 1974 to 1979. All were primary implantations. These cases were recently reviewed in a ten- to 14-year follow-up evaluation. Despite extensive laboratory testing of the ceramic material, a significant number of cases resulted in a very unfavorable result such as extensive wear, ball fracture, or migration of the socket. Whereas the patients had died or could no longer be traced in the case of 23 prostheses, there were 25 prostheses that had already been exchanged at the time of review for mechanical reasons (two stem fractures, eight ceramic ball fractures) and for component loosening attributable to wear of the alumina components. The remaining 52 prostheses still in place had good clinical results in 80%. However, roentgenographic evaluation of these prostheses revealed signs of loosening in six femoral components and in three sockets. Migration of more than 5 mm was evident in 24 sockets (46% of surviving prostheses). Although this had caused loosening in only three sockets at the time of review, further migration up to the limits of the acetabular region would be a major reason for future failures.     

The total condylar prosthesis. 10- to 12-year results of a cemented knee replacement

Over a two-year period 104 patients had 130 knee arthroplasties performed with the total condylar prosthesis at the Hospital for Special Surgery. At a 10- to 12-year review 58 patients (74 knees) had survived and were available for detailed clinical and radiographic evaluation. Of these, 38 knees (51.3%) were rated as excellent and 27 (36.5%) good. There were three (4.0%) fair and six (8.2%) poor results. Five of the six had had revision operations. The success of this early pattern of prosthesis supports the continued use of methacrylate cement for knee arthroplasties.     

Unicompartmental knee arthroplasty. Ten- to 13-year follow-up study

In the past decade, two concepts have caused considerable controversy in orthopedic surgery of the knee. Some orthopedic centers contend that osteotomy of the tibia is the procedure of choice for unicompartmental gonarthrosis of the knee and resist the concept of unicompartmental arthroplasty. The other concept is that if unicompartmental arthroplasty is necessary, the entire joint should be replaced, since the uninvolved compartment may develop arthritis in the future. This concept is illogical and contrary to the basic orthopedic principle of preserving normal structures whenever possible. It is obvious that joint replacements may not last the life of the patient and the need for revision must be considered; therefore, the original procedure should preserve as much bone stock as possible. The purposes of this review of unicompartmental replacement are to resolve these questions with data on long-term results of unicompartmental arthroplasty compared with data on high tibial osteotomy, to evaluate the cause of failures, and to improve future results. Eighty-seven consecutive unicompartmental arthroplasties were performed between November 1972 and April 1976. There were 60 knees available for study, with a minimum ten-year (average, 11-year) follow-up period. The results were evaluated using the Hospital for Special Surgery rating system, with 30 excellent, eight good, four fair, and 18 poor results. Seventy percent of the patients had satisfactory results, and pain relief was accomplished in 86.6% of patients. Of the 21 failures, the majority were due to material or technical problems and improper selection of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Insall-Burstein total knee replacement in osteoarthritis: a 10-year minimum follow-up.

A total of 99 Insall-Burstein posterior stabilized (IBPS) knee replacements were implanted in 86 osteoarthritic patients. We reviewed 60 knees with a 10- to 15-year follow-up. Using the Knee Society score, 35 knees (58%) were excellent, 15 (25%) good, 4 (7%) fair, and 6 (10%) poor. Flexion at follow-up was 106 degrees on average. Moderate patellofemoral crepitation was present in 5 knees (9%), and 11 knee required excision of a synovial nodule proximal to the patella. Radiographic analysis showed 5 osteolytic lesions (8%) around well-fixed tibial and femoral components and minimal (1 mm) narrowing of the medial polyethylene thickness in 7 knees (12%). There were 6 (10%) failures requiring reoperation because of aseptic loosening (4 knees), deep infection (1 knee), and recurrent patellar dislocation (1 knee). Survivorship analysis using revision as the endpoint showed a cumulative success rate of 92% at 10 years. In this study, the IBPS knee has shown good long-term results with low rates of aseptic loosening and no failures attributable to polyethylene wear.     

Dislocation of Insall-Burstein II modified total knee arthroplasty

Dislocation of total knee arthroplasty is a rare but serious complication. The experience with the Insall-Burstein II modified knee prosthesis, which was designed to address the issue of dislocation, has been favorable. We present a series of 3 dislocations in 1,500 total knee arthroplasties done with this prosthesis, accounting for about 0.2% of cases.     

Patellofemoral complications with the Insall-Burstein II posterior-stabilized total knee arthroplasty

The Insall-Burstein and Insall-Burstein II posterior-stabilized (I-B II PS) prostheses have been reported to have a high prevalence of patellar complications. This is a prospective, consecutive study of 118 primary total knee arthroplasties in 82 patients with the I-B II PS prosthesis implanted by 1 surgeon, using a specific technique for patellar resurfacing. The mean follow-up time was 4.0 years (range, 2-8 years). Clinical evaluation was performed using a standard knee score system with specific additional evaluation of the patellofemoral joint. Radiographs were evaluated for fracture, loosening, and subluxation. Ninety-four knees (80%) were rated excellent, 21 knees (17%) good, and 3 knees (3%) fair. The mean flexion was 112 degrees postoperative. No knee required reoperation for the patellofemoral joint. There were 2 nondisplaced and 1 minimally displaced patellar fractures treated nonoperatively, no patellar clunk syndrome, and no subluxations. Using the patellar evaluation system, 109 knees had no anterior knee pain, 7 knees had mild pain, and 2 knees (1 patient) had moderate-to-severe pain only with rising from a chair. Patellofemoral crepitus with active flexion-extension in the seated position was noted in 16 knees (14%) but was painful in only 2 knees (1 patient). With this technique for patellar resurfacing with this prosthesis, patellofemoral complications were only 4.2%, and no knee required reoperation for the patella or for loosening. With attention to operative technique, patellofemoral resurfacing with this posterior-stabilized total knee arthroplasty can be highly successful.     

Uncemented rotating-platform total knee arthroplasty: a 4-year to 12-year follow-up

One hundred nine primary uncemented, rotating-platform, low-contact stress total knee arthroplasties in 85 patients were reviewed 4 to 12 years after the operation as a prospective study on consecutive cases. All patients were followed up annually with subjective questionnaires and radiological assessment. At the time of final review, 69 patients with 87 rotating-platform total knee arthroplasties were still alive. All were reviewed at the final follow-up using the American Knee Society Score (clinical and radiological). The average knee score was 86.42, and the average functional score was 65.1. No evidence of radiological loosening was observed in any patient. One knee was revised because of medial collateral ligament laxity. The 10-year survival rate was 99.08%.     

Posteriorly stabilised (Insall-Burstein) total condylar knee arthroplasty

Summary We reviewed 157 knees in 118 patients who underwent posteriorly stabilised (Insall-Burstein) knee replacement arthroplasty. Their mean age at operation was 69 years (range 47 to 85 years) and the average follow-up was 3.5 years (range 2 to 7 years). The BASK knee function assessment chart was utilised to evaluate the functional and clinical results. One hundred and thirty-five knees (86%) had excellent or good results, 16 knees (10%) had fair results and six (4%) had poor results. The mean postoperative BASK score was 79 points and the average postoperative knee flexion was 95° (range 65° to 130°). Two patients had a superficial infection, one deep sepsis requiring revision arthroplasty and two mechanical loosening. Patellar impingement symptoms were present in 8% of the knees, although they were troublesome in less than half. Varus alignment of the knee and a varus tilt of the tibial component of more than 2° correlated with the incidence of radiolucent lines around the tibial prosthesis. 90% of the patients were pleased or satisfied with the functional result. The total condylar knee is a safe, reliable and versatile prosthesis.

---

Résumé Nous avons revu 157 genoux chez 118 malades ayant bénéficié d'une arthroplastie par prothèse semi-contrainte (Insall-Burstein). L'âge moyen lors de l'opération était de 69 ans (de 47 à 85) et le recul moyen était de 3 ans et demi (de 2 à 7). Pour évaluer les résultats fonctionnels et cliniques, nous avons eu recours à l'échelle de cotation fonctionnelle «BASK». Le résultat était excellent ou bon dans 135 genoux (86%), moyen dans 16 (10%) et mauvais dans 6 (4%). La cotation post-opératoire «BASK» était en moyenne de 79 points et la flexion post-opératoire moyenne de 95° (de 65° à 130°). Deux opérés avaient présenté une infection superficielle, un seul un sepsis profond ayant nécessité une reprise de l'arthroplastie et deux un descellement mécanique. Des signes d'hyperpression rotulienne pouvaient être notés dans 8% des genoux mais ils n'avaient de traduction clinique que dans moins de la moitié des cas. L'existence d'un liseré autour de la pièce tibiale êtait correlée avec une désaxation du genou en varus ou avec un positionnement en varus du composant tibial supérieur à 2°. La prothèse total-condylar est donc sûre, efficace et susceptible de s'adapter aux diverses éventualités.

---

---

Reprint requests to: P. M. Aichroth     

The Insall-Burstein II prosthesis: a 5- to 9-year follow-up study in osteoarthritic knees

We prospectively studied 100 Insall-Burstein Posterior Stabilized II total knee arthroplasties (Zimmer Inc, Warsaw, IN) consecutively implanted in 91 patients with osteoarthritis. We reviewed 92 knees in 85 patients at a mean follow-up of 7.5 years (range, 5.3-9.5 years). According to the Knee Society score, 78 (85%) results were excellent, 11 (12%) were good, and 3 (3%) were fair or poor. The unsatisfactory results were attributed to patellofemoral pain with a low patella (2 knees) and to valgus alignment and medial laxity (1 knee). Flexion at follow-up averaged 116 degrees. Nonprogressive radiolucent lines were present around 30% of the tibial components. There was only 1 small osteolytic lesion around the tibial plateau. We observed no aspetic loosening, infection, or patella stress fracture. Survivorship analysis in the worst-case scenario showed a 90.9% success rate at 8 years.     

Long-term followup of nonmodular total knee replacements

The purpose of the current study was to evaluate and determine the mechanism and etiology of failure of components that failed in long-term followup of Anatomic Graduated Component total knee replacements. The authors previously reported the survivorship of 4583 Anatomic Graduated Component total knee arthroplasties done during a 17-year period. The current study was done to evaluate the etiology and cause of failure of the components that failed. There were six (0.18%) failures of the femoral component. There were 21 tibia components that failed (0.46%). Twelve tibial components failed because of an osteonecrotic lesion in the medial tibia plateau. The clinical survival rate with revision or loosening of one or more components was 98.9% at 15 years. No component was revised for polyethylene wear or osteolysis. This total knee replacement has proved to have minimal wear and excellent longevity with time with no revisions between 10 and 15 years despite having nearly flat-on-flat geometry and retaining the posterior cruciate ligament. The most common cause for revision (12 tibial components) was because of an osteonecrotic lesion in the medial tibia plateau, which developed after surgery and led to loosening.     

Long-term followup after mobile-bearing total knee replacement

Clinical and radiographic analyses and survivorship were done on the initial cementless series of 309 posterior cruciate-retaining meniscal-bearing and rotating-platform New Jersey LCS total knee replacements followed up for 10 to 20 years (mean, 12.4 years). Clinical results in patients surviving at least 10 years using a strict knee scoring scale were similar for posterior cruciate ligament-retaining and posterior cruciate ligament-sacrificing designs. Good to excellent results were seen in 97.9% of primary posterior cruciate-retaining-bearing prostheses and in 97.9% of primary rotating-platform prostheses. Radiographic analysis of minimum 10-year followup radiographs showed generally stable fixation of all components with gross migration seen in one tibial component (0.6%) in a patient with a failed high tibial osteotomy. Significant osteolysis was present requiring bearing exchange and bone grating in three patients with cementless rotating-platform prostheses (1.8%) who had multiple knee surgeries at an average of 10.2 years from the index surgery. Survivorship of the primary cementless posterior cruciate-retaining meniscal-bearing prostheses with an end point of revision for any mechanical reason was 97.4% at 10 years and 83% at 16 years; using an end point of a poor clinical knee score, the survivorship was 98.9% at 10 and 16 years, respectively. Survivorship of the primary cementless rotating-platform prostheses with end points of revision for any mechanical reason or a poor clinical knee score was 98.3% survivorship at 10 and 18 years, respectively. In the current study, no cementless rotating-bearing patella loosened, fractured, or dissociated in patients without prior knee surgery although one cementless rotating-bearing patella (0.6%) in a patient who had multiple knee surgeries wore through the inferior marker wire after 10.8 years, causing metallosis that required revision.     

Long-term followup of the Miller-Galante total knee replacement.

One hundred seventy-two consecutive cemented Miller-Galante-I total knee arthroplasties in 155 patients were compared with 109 consecutive cemented Miller-Galante-II total knee arthroplasties in 92 patients. The average followup was 11 years (range, 8-15 years) and 9 years (range, 8-10 years), respectively. Of the 172 Miller-Galante-I arthroplasties, there have been 21 revisions; 15 patellar revisions; two included femoral revisions attributable to abrasion. Six additional well-fixed femoral and tibial components were revised: two for early instability, one for pain, one for periprosthetic fracture, and two for infection. No component had aseptic loosening or osteolysis. Using revision or loosening of any components as the end point, the Kaplan-Meier 10-year survivorship was 84.1% +/- 4.1%. Of the 109 Miller-Galante-II arthroplasties, there have been no component revisions, no aseptic loosening, and no osteolysis. Using revision or loosening of any components as the end point, the Kaplan-Meier 10-year survivorship was 100%. The Miller-Galante knee systems showed excellent fixation with no loosening and no osteolysis at as many as 15 years. Additionally, there have been no component revisions for late instability at as many as 15 years. Finally, the high prevalence of patellofemoral complications with the Miller-Galante-I design has been obviated with the Miller-Galante-II design.