Posterior cruciate ligament-retaining total knee arthroplasty in patients with rheumatoid arthritis: a concise follow-up of a previous report

7We previously reported the minimum eight-year follow-up results of cruciate-retaining total knee arthroplasty in a consecutive series of seventy-two knees in patients with rheumatoid arthritis. In the present study, we evaluated the longer-term outcomes after twenty to twenty-five years of follow-up. Since the publication of our original study, ten knees have been revised: three because of periprosthetic fracture, three because of infection, two because of patellofemoral failure, and two because of posterior instability. The rate of implant survival at twenty years after surgery was 69% (95% confidence interval [CI], 56% to 79%) with revision for any reason as the end point, 81% (95% CI, 69% to 89%) with femoral or tibial component revision for any reason as the end point, and 93% (95% CI, 83% to 97%) with posterior instability as the end point. These long-term results demonstrate that posterior cruciate ligament insufficiency with instability was rarely the cause of failure following cruciate-retaining total knee arthroplasty in patients with rheumatoid arthritis.     

Posterior cruciate ligament-substituting total knee arthroplasty in young rheumatoid patients with advanced knee involvement

The integrity and strength of the posterior cruciate ligament (PCL) in the rheumatoid knee are known to be suboptimal. However, the results of PCL-substituting total knee arthroplasty in rheumatoid patients are not well documented. We reviewed 86 PCL-substituting total knee arthroplasties in 52 rheumatoid patients with grade IV or V radiographic disease. The mean age at surgery was 41.9 years. All patients underwent follow-up evaluation for an average of 7.8 years. Revision was performed for 1 knee because of aseptic loosening of the tibial component, and for 3 knees because of deep infection. An isolated insert exchange was performed on one knee. Using revision of any component for aseptic loosening or radiographic loosening as the end point, the mean 10-year survival rate was 94.0%.     

Posterior polyethylene wear in posterior cruciate ligament-retaining total knee arthroplasty: A case study

Controversy over whether to retain the posterior cruciate ligament (PCL) during primary total knee arthroplasty continues. Both the retaining and substituting designs have their respective advantages and disadvantages. In order to capitalize on the advantages of the PCL retaining design, precise techniques in ligament balancing are required. An incorrectly tensioned PCL—too tight or too loose—may exaggerate the disadvantages of the retaining design and lead to early catastrophic failure. Three cases of early catastrophic posterior wear are presented. Although no definite documentation of excessive PCL tension is available, the authors feel that this may have had a significant role in the etiology of this wear pattern. Possible causes of incorrect PCL tension as well as intraoperative techniques to balance the PCL properly are discussed.     

Anteroposterior stability in posterior cruciate ligament-retaining total knee arthroplasty

Anteroposterior stability was evaluated using a KT-2000 arthrometer in 18 patients (21 knees) continuously for up to 5 years after posterior cruciate ligament-retaining total knee arthroplasty. The Knee Society score, functional score, and the maximum flexion angle did not change significantly during the postoperative period. The mean anteroposterior displacement of all joints studied at both 30 degrees and 75 degrees of flexion did not change significantly during the 5-year period of observation, but 4 individual knees did exhibit increases in anteroposterior displacement of 3 mm or more. One of the 4 knees exhibited osteolysis beneath the tibial component. Three of these knees had undergone high tibial osteotomy at some time before the total knee arthroplasty.     

Posterior cruciate recession in total knee arthroplasty

Incremental recession of the posterior cruciate ligament (PCL), as a part of ligamentous balancing in total knee arthroplasty, is critical if the PCL is too tight. This study was undertaken to evaluate any possible untoward effects of PCL recession. Twenty-one patients who underwent simultaneous bilateral total knee arthroplasty between 1988 and 1992 with a PCL recession performed only on one side (necessary to balance the knee) served as the study group. The average follow-up period was 4 years. The patients were evaluated subjectively, by manual physical testing, by radiography, and by KT-1000 arthrometry (Medmetric, San Diego, CA). There were no significant differences between the recessed and nonrecessed knees. The conclusion is that PCL recession is appropriate and safe long-term for the patient in whom the PCL is found to be too tight at the time of knee arthroplasty.     

Sagittal laxity after posterior cruciate ligament-retaining mobile-bearing total knee arthroplasty

Posterior cruciate ligament stretching after posterior cruciate ligament-retaining (CR) total knee arthroplasty (TKA) can lead to an increase in sagittal laxity, knee dysfunction, or accelerated damage to the tibial bearing surface. We conducted a prospective study on 74 consecutive mobile-bearing CR TKA to determine if knee laxity changed with time or if knees with large initial laxity experienced greater increases in laxity. Patients were studied with radiographic posterior and anterior drawer examinations at 3 and 23 months. Model-based shape-matching techniques were used to measure TKA kinematics. We found a 1-mm increase in posterior drawer. Knees with large postoperative drawers did not exhibit increased laxity at last follow-up. The use of a mobile-bearing CR TKA did not significantly modify the midterm knee sagittal laxity.     

Simultaneous bilateral total knee arthroplasty in patients with rheumatoid arthritis

AIM: In the event of destruction of both knee joints, is bilateral total arthroplasty a reliable operation that the patient can reasonably be expected to undergo? METHOD: In 140 patients [35 men, 105 women, average age 48.6 (range 24-78) years], a bilateral sequential TEP implantation was performed under one anaesthesia session, due to verified destruction of both knee joints (Larsen stage III-IV). All patients were treated with a cemented surface replacement prosthesis with resurfacing of the patella (Duracon Total Knee System, Stryker/Howmedica). Functional assessment was done with the aid of the Lysholm score preoperatively as well as 6, 12 and 18 months postoperatively. RESULTS: The operation was conducted under one anaesthesia session in all patients. The average Lysholm scores improved from 26 (19-45) preoperatively, to 72 (49-81) 6 months postoperatively, 76 (48-85) 12 months postoperatively and 77 (49-87) 18 months postoperatively, whereby no significant difference between sides was observed. 96% of the patients said that they would undergo the operation again. The following complications occurred: 6 prosthesis infections (2.1%), 2 aseptic loosenings (0.7%), 8 superficial wound healing disorders (2.9%) and 2 deep vein thromboses (0.7%). CONCLUSION: Sequential bilateral total knee arthroplasty under one anaesthesia session in patients with rheumatoid arthritis facilitates a much quicker rehabilitation, while the overall perioperative risk is not increased.     

Early,incapacitating instability of posterior cruciate ligament-retaining total knee arthroplasty

Numerous studies indicate that total knee arthroplasty (TKA) achieves excellent long-term success whether the posterior cruciate ligament (PCL) is saved or excised. In 13 patients, 16 PCL-retaining TKAs were identified with incapacitating instability secondary to early PCL deficiency. Patients with clinical PCL insufficiency present with a triad of subjective complaints: persistent swelling/effusions, anterior knee pain, and giving-way or instability episodes with activities of daily living. Of 13 patients, 12 had at least three postoperative visits with identical subjective complaints before PCL deficiency was diagnosed. On examination all patients exhibited effusion, posterior sag, positive quadriceps active test, and a visible anterior translation of the tibia on the femur while extending the leg from a seated, 90° flexed position. This sign has not been previously described to our knowledge but was present in all of our study patients. No patients had radiographic evidence of loosening or osteolysis. Joint aspiration was negative for infection in all patients. No patient had lateral patellofemoral maltracking. By radiographic measurement, the PCL-deficient knees had an average joint line elevation of 10.3 mm, compared with well-functioning TKAs which had an average joint line elevation of 5.0 mm. There was no correlation of PCL deficiency with excessive proximal tibial resection. Nonsurgical intervention provided no improvement in pain or instability. Six patients had improvement of pain, effusion, and stability after revision to a cruciate-substituting implant. We believe that this complication occurs more frequently than is currently being identified and should be considered in problem TKAs with normal radiographs.     

晚期类风湿性关节炎合并屈膝位强直的人工全膝关节置换术

目的 :探讨重症类风湿性关节炎膝关节屈曲位强直患者行全膝关节置换的正确截骨及后关节囊软组织松解方法和疗效。方法:对2009年11月至2012年1月收治的15例晚期类风湿性关节炎患者17个屈膝位强直的膝关节行人工膝关节表面置换手术。男7例,女8例;年龄22~75岁,平均58.7岁;单膝13例,双膝2例。15例17膝均表现为屈膝位纤维性强直或僵直畸形,膝关节屈伸活动度(3.2±1.7)°。术前膝关节学会评分系统(KSS)临床评分23.3±12.5,功能评分35.2±9.8。术中在准确截骨的基础上,对不同程度的膝关节屈曲强直畸形采取不同的后关节囊软组织松解方法。结果:15例均获随访,时间1.6个月~3年,平均2.3年。末次随访时KSS临床评分81.7±6.5,较术前提高;功能评分82.8±9.3,较术前提高。2例3膝遗留5°~7°屈膝畸形,但患膝关节功能良好。结论:正确的截骨及有效的后关节囊软组织松解是矫正屈膝位强直畸形和假体置换的关键,其中有针对性的膝关节后房室结构松解的方法和步骤可避免过量截骨并获得满意的换膝间隙。     

Posterior cruciate ligament balancing during total knee arthroplasty

This study was undertaken to describe and evaluate the use of a posterior cruciate ligament balancing technique in total knee arthroplasty. Two hundred sixty total knee arthroplasties in 156 patients were performed between January 1984 and December 1985 using the described technique of posterior cruciate ligament balancing when necessary. Seventy-eight arthroplasties (30%) required ligament balancing to obtain a smooth flexion arc. At 1-year minimum follow-up evaluation, no knee was found to be unstable in the anterior-posterior plane. Average flexion arc for the posterior cruciate ligament balanced knees was 2 degrees - 114 degrees and for the standard arthroplasty was 2 degrees - 107 degrees. Posterior cruciate ligament balancing is a useful adjunct in total knee arthroplasty surgery when flexion gap tightness occurs.     

人工全膝关节置换术治疗膝关节类风湿性关节炎中短期疗效随访

目的：为了观察人工全膝关节置换术（ TKA）治疗膝关节类风湿性关节炎（ RA）的中短期治疗效果。方法随访2007至2011年间行TKA治疗的38例（58膝）膝关节RA患者。采用HSS评分、KSS评分、WOMAC评分、VAS视觉疼痛评分对术前及术后患者的膝关节功能进行评价、同时对术后随访影像学资料进行评价;采用SF-36量表对患者健康状况进行评价。结果所有患者均未出现感染且获得平均3.3年（2～6年）随访,膝关节功能均明显改善,患者膝关节HSS评分由术前45.92±13.49分提高到术后88.19±5.98分,两者采用配对t 检验比较差异有统计学意义（ P ＝0.00）,其中优21膝,良34膝,优良率94.83％。膝关节屈曲畸形明显改善,膝关节活动度（ROM）由术前71.81°±32.58°提高到术后100.98°±13.99°,两者比较差异有统计学意义（ P＝0.00）。膝关节假体X线片采用膝关节学会的X线评价与计分系统评价未见假体松动。 SF-36评分中PCS由术前的26.27±3.91分提高到术后48.09±6.65分,两者比较差异有统计学意义（ P＝0.00）;MCS由术前的41.59±5.61分提高到51.83±5.44分,两者比较差异有统计学意义（ P＝0.00）。结论 TKA是治疗膝关节RA的有效方法,可提高患者生活质量。     

Posterior cruciate condylar total knee arthroplasty. Five-year results

A series of 189 consecutive posterior cruciate condylar total knee arthroplasties (TKAs) in 151 patients was reviewed. Of these, 18 patients died (22 knees), and two patients (three knees) were lost to follow-up study, leaving 164 knees in 131 patients for evaluation at 5.3 +/- 0.8 years (mean +/- SD). Before surgery 91% of the patients experienced moderate to severe pain with weight bearing, whereas 6% had such pain at five years. The average motion was -5 degrees -107 degrees before surgery and -1 degrees -101 degrees at last examination. The percentage of patients who could walk more than six blocks (600 m) increased from 9% preoperatively to 61% at last examination. The percentage of patients who could independently climb stairs increased from 37% preoperatively to 69% at last examination. Hospital for Special Surgery (HSS) scores improved an average of 29 points, from 57 preoperatively (poor) to 86 (excellent) at last examination. Complications included an overall reoperation rate of 3.7% (seven knees), with a revision rate of 1.6% (three knees). Lucent lines greater than or equal to 1 mm at five years were present in 6% of knees and progressed in 3%. Overall, the results after posterior cruciate-sparing TKAs were excellent, with few complications.     

Mortality after total knee arthroplasty in patients with osteoarthrosis and rheumatoid arthritis

Total knee arthroplasty (TKA) is a widely used procedure in the treatment of severe destruction of the knee joint because of osteoarthrosis (OA) or rheumatoid arthritis (RA). The aim of this study was to explore whether there is an increased mortality in patients after TKA with the underlying diagnosis OA or RA compared with the general population. We studied a consecutive series of 422 primary TKAs with a hinged Blauth prosthesis in 330 patients (OA: 208 patients, 175 women, 33 men; RA: 122 patients, 109 women, 13 men) with a mean follow-up of 6 years (range 0-20 years). The mean age of the patients at the time of surgery was 70 years (range 29-87 years), being 72 years (range 46-87 years) for OA, and 66 years (range 29-84 years) for RA. Age standardized mortality ratios (SMRs) were calculated for OA and RA. In patients with OA, the SMR was 1.03 (95% CI 0.76-1.37) for women and 1.14 (95% CI 0.68-1.80) for men. SMRs of patients suffering from RA showed a clear shortening of the life span (women: 2.92, 95% CI 2.17-3.85; men: 3.09, 95% CI 1.0-7.19). In spite of the risk of intra- and perioperative complications and further operative procedures necessary because of late complications, the implantation of a knee prosthesis per se does not necessarily significantly reduce the life expectancy in patients with OA. Patients with RA who require the implantation of a total knee prosthesis obviously represent a high-risk group with a high mortality rate.     

Cemented ceramic YMCK total knee arthroplasty in patients with severe rheumatoid arthritis

Total knee arthroplasty (cemented) using a ceramic Yokohama Medical Ceramic Knee (YMCK) (Kyocera Corp; Kyoto, Japan) prosthesis was evaluated in 90 knees of 64 patients with severe rheumatoid arthritis, with a mean age of 59 +/- 11 years. The mean follow-up period was 56 +/- 20 months (range, 27 to 97 months). Larsen's grading of rheumatoid arthritis revealed grade 2 in 3, grade 3 in 36, grade 4 in 36, and grade 5 in 15 of 90 knees. Of 64 patients, 9 were judged to have class 1, 30 were judged to have class 2, and 25 were judged to have class 3 functional disability. The American Knee Society knee score and function score improved from 41 +/- 16 and 29 +/- 22 preoperatively to 83 +/- 14 and 50 +/- 29 at the final follow-up (P <.0001) even in patients with multiple joint involvement. Radiographs at the final follow-up showed satisfactory insertion of all prostheses, with no osteolysis. A radiolucent line measuring <1 mm was observed around the tip of the pegs of the patellar dome in 3 knees. Complications consisted of infection (1 case) and femoral fractures (3 cases). There were no cases of ceramic fractures.     

In vivo function of posterior cruciate ligament before and after posterior cruciate ligament-retaining total knee arthroplasty

Purpose

The object of this study was to investigate the in vivo function of the posterior cruciate ligament (PCL) in patients before and after a PCL-retaining total knee arthroplasty (TKA).

Methods

Eleven patients with advanced osteoarthritis (OA) of the knee were recruited. Magnetic resonance scans of each OA knee were obtained, and 3D computer models, including the femoral and tibial insertion areas of the anterolateral and posteromedial bundles of the PCL, were created. Before and after PCL-retaining TKA, dual fluoroscopic images of each knee were acquired during weight-bearing knee flexion. The images and computer models were used to reproduce the in vivo motion of the knee. The function of the PCL bundles was described in terms of elongation, elevation and deviation. Twenty-two healthy controls were also included as normal references.

Results

PCL bundles of the OA knees were overstretched during late knee flexion and orientated more medially throughout flexion compared with normal knees. After PCL-retaining TKA, PCL bundles were further overstretched during late flexion and changed from medially directed in normal and OA knees to almost sagittally directed, which may compromise function in controlling knee rotation.

Conclusions

The current PCL-retaining TKA systems and surgical techniques may not adequately re-establish normal biomechanics of PCL bundles after PCL-retaining TKA.     

Long-term results of cemented, posterior cruciate ligament-retaining total knee arthroplasty in osteoarthritis.

Two hundred fifty-four total knee arthroplasties (TKAs) in 223 patients (82 men and 141 women) with osteoarthritis were reviewed. Average patient age at surgery was 68 years (range: 37-90 years). No patient was lost to follow-up. Average follow-up was 16.8 years (range: 15.2-23.2 years). Preoperatively, 175 (69%) knees had a varus deformity. The posterior cruciate ligament (PCL) was retained in all 254 knees, and all prostheses were cemented. Clinically, 91% of knees were rated as excellent; however, functionally, only 23% of knees were rated as excellent. There were 13 (5%) complications. Revision was performed in 10 (4%) knees. Survivorship analysis showed average implant survival for all revisions was 96.3% (range: 91.9%-98.3%) at 15 years and 82% (range: 60%-92.6%) at 23 years. Long-term results of cemented, PCL-retaining TKA for osteoarthritis are excellent in terms of improved clinical function and pain relief.     

15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis

In 25 patients with rheumatoid arthritis, 36 cases of cemented Kinematic total knee arthroplasty were reviewed clinically and radiographically at 13 to 19 years after surgery. The mean age at the time of surgery was 51.6 +/- 8.9 years. According to the follow-up results evaluated with the Hospital for Special Surgery knee scoring system, 28 knees (77.7%) were classified as good or excellent. The mean flexion angle at follow-up evaluation was 99 degrees +/- 24 degrees (10 degrees -140 degrees ). At the tibial or femoral bone-cement interfaces, a radiolucent line was seen in 10 of 36 knees (27.8%) at follow-up evaluation. The survival rate of prostheses with revision as the endpoint was estimated to be 93.7% at 15 years. Kinematic total knee arthroplasty in rheumatoid arthritis patients provided a good long-term outcome.     

The effect of distal femoral resection on passive knee extension in posterior cruciate ligament-retaining total knee arthroplasty

Full passive extension in total knee arthroplasty is predicated on creating a large enough extension gap to accommodate any given combined thickness of femoral and tibial components. Additional distal femoral resection can achieve more passive knee extension. The predictable effect of further distal femoral resection has never been studied. We designed a simple institutional review board-approved, intraoperative study to quantify this effect. Routine posterior cruciate ligament-preserving total knee arthroplasty was performed with measured femoral and tibial resections, yielding full passive extension with trial components. Distal femoral augments were then sequentially applied to the back of the femoral trial component, and passive knee extension was measured. The data show that an average value of 9 degrees of femoral contracture is corrected for every 2 mm of distal femoral resection.