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.     

Total knee arthroplasty with posterior cruciate ligament retention

Total knee arthroplasty with posterior cruciate ligament retention requires strict attention to the restoration of femoraland tibial anatomy, restoration of the joint line, and soft-tissue balancing. Component sizing and orientation are dependent on an understanding of normal knee anatomy and play a critical role in the success of the reconstruction. The results of knee arthroplasty with this technique have been excellent, and with continued refinements in prosthesis design and polyethylene manufacturing and sterilization, total knee arthroplasty with posterior cruciate ligament retention should continue to play a significant role in the management of patients with debilitating arthritis of the knee.     

Total knee arthroplasty with the kinematic prosthesis. Results after five to nine years: a follow-up note

A review of the results of 192 kinematic total knee replacements five to nine years after the operation showed that the results were still satisfactory. At the time of the review, the ages of the patients ranged from twenty-two to eighty-seven years. About half of the patients had rheumatoid arthritis and the other half, osteoarthrosis. About 90 per cent of the results were rated good or excellent, and the average range of flexion was 109 degrees. Radiolucency was present around 40 per cent of the tibial components, 30 per cent of the femoral components, and 60 per cent of the patellar components, but the lines were thin and not progressive. The complications included loosening of the patellar components in five knees, one fracture of the tibial tray with loosening of the patellar component, one fracture of the patellar component, and one dislocation of the patellar component.     

Total knee arthroplasty in juvenile rheumatoid arthritis. A seven-year follow-up study

Total knee arthroplasty (TKA) for preservation of ambulation is indicated in young adults with juvenile rheumatoid arthritis (JRA). The bony deformities of JRA require special measures to adequately seat the prosthesis. Thirteen patients with 25 knee arthroplasties were followed an average of 61 months. Prior surgical operations did not affect the outcome of this procedure. A 55% reduction in pain plus an average 30-point gain on Jergesen's functional assessment scale reflected the overall improvement attributable to TKA. To date, no revisions, infections, or loosenings have occurred in this series of patients.     

Total knee arthroplasty ligament balancing and gap kinematics with posterior cruciate ligament retention and sacrifice

This cadaver study was undertaken to gain insight into the effects that posterior cruciate ligament retention and sacrifice would have on the amount of deformity correction obtained with medial and lateral structure release during total knee arthroplasty. Twenty-seven cadaveric specimens were used to sequentially release medial and lateral structures with and without posterior cruciate support. Each release sequence was tested in full extension and 90 degrees flexion. In full extension, the resulting change into valgus after release of the posterior cruciate ligament, posteromedial capsule/oblique ligament complex, superficial medial collateral ligament, and pes anserinus and semimembranosus tendons was 6.9 degrees, and it increased to 13.4 degrees in 90 degrees flexion. With preservation of the posterior cruciate ligament this decreased to 5.2 degrees in extension and 8.7 degrees in flexion. Changes seen in 90 degrees flexion were significantly greater than those in full extension. For the valgus knee model with release of the posterior cruciate ligament, posterolateral capsule, lateral collateral ligament, iliotibial band, popliteus tendon, and lateral head of the gastrocnemius, 8.9 degrees of change into varus was seen in extension and 18.1 degrees in 90 degrees flexion. With posterior cruciate ligament retention 5.4 degrees and 4.9 degrees of change into varus was seen in extension and flexion, respectively. Significantly less change with retention of the posterior cruciate ligament was seen with both medial and lateral release and more opening of the flexion gap was seen on the release side of the joint for all groups except those with lateral release with sacrifice of the posterior cruciate ligament.     

Cemented rotating-platform total knee replacement. A nine to twelve-year follow-up study

BACKGROUND: Although the LCS (low contact stress) rotating-platform mobile-bearing knee replacement has been used extensively, there have been few intermediate or long-term clinical and radiographic follow-up studies evaluating the device. The purpose of this study was to report the nine to twelve-year results of a consecutive series of patients who had a primary total knee replacement performed with this device. METHODS: Between November 1985 and November 1988, the senior author (R. C. J.) performed 119 consecutive total knee arthroplasties in eighty-six patients with LCS rotating-platform femoral and tibial components and a Townley all-polyethylene dome patellar component. All components were fixed with cement. The average age of the patients at the time of the operation was seventy years (range, thirty-seven to eighty-eight years). Fifty-two patients (seventy-six knees) were female, and thirty-four patients (forty-three knees) were male. The patients were evaluated with clinical knee ratings and radiographic analysis nine to twelve years following the knee replacement. RESULTS: At the time of the nine to twelve-year follow-up, sixty-four patients (eighty-six knees) were alive, eighteen patients (twenty-eight knees) had died, and four patients (five knees) had been lost to follow-up. Of the 114 knees in the eighty-two patients for whom the final outcome was known, none required a reoperation and none had a dislocation of the mobile-bearing prosthesis. For the forty-five patients (sixty-six knees) who returned for final clinical and radiographic follow-up examinations at nine to twelve years, the average clinical and functional Knee Society ratings were 30 points (range, 2 to 70 points) and 44 points (range, 0 to 80 points) preoperatively and 90 points (range, 63 to 102 points) and 75 points (range, 30 to 100 points) at the final follow-up evaluation. The average Hospital for Special Surgery knee rating was 57 points (range, 28 to 80 points) preoperatively and 84 points (range, 59 to 97 points) at the final follow-up evaluation. The average active range of knee flexion was from 0 degrees (range, 0 to 10 degrees) to 102 degrees (range, 15 to 120 degrees) at the final follow-up evaluation. Seven of the sixty-six knees were painful anteriorly. There was no periprosthetic osteolysis and no evidence of loosening on follow-up radiographs. CONCLUSIONS: After nine to twelve years of follow-up, the cemented LCS rotating-platform knee replacement was found to be performing well, with durable clinical and radiographic results.     

Symptomatic ganglion cysts of cruciate ligaments of the knee: A series of nine cases

BackgroundGanglion cysts of cruciate ligaments of the knee are uncommon, especially because a proportion of them are asymptomatic. Moreover, symptomatic lesions have diverse presentation and are not easily detected in physical examinations. The purpose of this report was to define the relationship between clinical symptoms and the sites of ganglia of cruciate ligaments of the knee.Materials and methodsWe conducted a retrospective review of a series of nine patients treated at our institute for intra-articular ganglion cysts of cruciate ligaments of the knee. One patient presented with pain and an inability to fully extend the knee. The remaining eight patients presented with nonspecific pain or pain during knee flexion and/or extension. The diagnosis and definite location of ganglia of cruciate ligaments were confirmed by arthroscopy. All patients were treated by ganglionectomy using arthroscopic techniques.ResultsSubstantial cyst impingements were observed during knee motion using arthroscopy. At the last follow-up, all but one patient had achieved considerable symptomatic improvement after arthroscopic ganglionectomy.ConclusionWe suggest that depending on cyst location, a more applicable hypothesis for knee joint pain during motion is cyst impingement on the other cruciate ligament or the intercondylar notch.     

Total knee arthroplasty after anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) injuries are common, and many of these patients go on to ACL reconstruction. At a later date, some may develop symptomatic osteoarthritis and require total knee arthroplasty (TKA). This raises the question: Does prior ACL reconstruction have a deleterious impact on the outcome of knee arthroplasty? Thirty-six cases of patients who underwent ACL reconstruction and then TKA at a later date were retrospectively reviewed. A cohort of patients without ACL injuries who underwent TKA for the diagnosis of primary osteoarthritis were selected to serve as controls. The results of this study demonstrate that previous ACL reconstruction does not have a negative impact on the outcome of future TKA with respect to range of motion, outcome scores, infection, or patella baja.     

Polycentric total knee arthroplasty. A ten-year follow-up study

After review of the first 209 polycentric total knee arthroplasties (in 159 patients) performed at the Mayo Clinic between July 1970 and November 1971, we found that the calculated probability of the arthroplasty remaining successful ten years postoperatively was 66 per cent. Actual results showed 42 per cent of the arthroplasties to be successful in patients who were still alive at review; another 24 per cent were successful but were in patients who had died or were lost to follow-up before ten years postoperatively. In 34 per cent failure occurred, which we defined as reoperation for any reason, unacceptable pain, or loss of function. The most common causes of failure were instability or ligament laxity (13 per cent), loosening of a component (7 per cent), infection (3 per cent), and patellofemoral joint pain (4 per cent). Prior knee surgery significantly decreased the probability of success, as did axial malalignment of the prosthetic components at operation.     

Posterior cruciate condylar total knee arthroplasty. Average 11-year follow-up evaluation.

Forty-two total knee arthroplasties (TKAs) of the posterior cruciate condylar design performed from 1975 until 1978 were reviewed. Follow-up evaluations averaged 11 years. There were 21 knees each of osteoarthrosis and rheumatoid arthritis. The average postoperative knee score was 85.4 points. Thirty-nine knees (92.8%) were rated good or excellent, one (2.4%) was judged fair, and two (4.8%) were considered failures. Postoperative flexion averaged 104 degrees. Analysis of osteoarthritic versus rheumatoid arthritic subgroups demonstrated no significant differences in motion, alignment, or knee score. Roentgenographic review demonstrated no cases of femoral or tibial loosening, but one case of patellar component dislodgement was observed. Nonprogressive radiolucent lines were observed in 75% of the cases. Good results can be expected if satisfactory lower-extremity alignment is attained. Posterior cruciate ligament retention has provided a slightly improved postoperative range of motion. Residual problems appear to be centered about the patellofemoral joint.     

Primary cementless total hip arthroplasty in octogenarians. Two to eleven-year follow-up

BACKGROUND: Cementless total hip arthroplasty is an accepted alternative to total hip arthroplasty with cement in younger patients, but it remains controversial for elderly patients. The purpose of this study was to evaluate the clinical and radiographic outcomes of cementless total hip arthroplasty with use of a proximally coated stem in patients who were at least eighty years of age at the time of the operation. METHODS: One hundred and twenty-three cementless total hip replacements were performed for the treatment of osteoarthritis in 114 patients between the ages of eighty and eighty-nine years. Seven patients (eight hips) died within two years after the surgery, seventeen patients (eighteen hips) died more than two years postoperatively but were not followed for at least two years, and five hips were lost to follow-up; this left ninety-two hips in eighty-six patients for review. The mean duration of follow-up was five years (range, two to eleven years). For the clinical evaluation, the Charnley modification of the Merle d'Aubigné and Postel scale was used. In addition, preoperative and postoperative Harris hip scores were available for sixty-nine hips. Seventy-eight hips were followed radiographically for two years or more. The focus of the radiographic evaluation was the status of the fixation of the femoral and acetabular components as well as cup wear. RESULTS: Perioperative medical complications occurred in association with 24% (thirty) of the 123 operations, but there were no deaths. The mean Charnley scores for pain and function for the ninety-two hips that were followed clinically for at least two years improved by 3.0 and 1.4 points, respectively. The sixty-nine hips for which preoperative and postoperative Harris hip scores were available had a mean improvement of 42 points, with a mean score of 82 points at the last follow-up evaluation. Mild thigh pain was present in four patients, but it did not limit their activity. There were no femoral component revisions. All of the femoral components were radiographically stable and had bone ingrowth. No acetabular component failed by loosening, but 41% (thirty) of the seventy-three hips with radiographs available for measurement of wear showed polyethylene wear. Of the seventy-eight cups that were followed radiographically for two years or more, 4% (three) were associated with lysis, but none had been revised. CONCLUSIONS: Cementless fixation in the elderly is safe, effective, and durable at the time of two to eleven-year follow-up.     

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)     

Unilateral aplasia of both cruciate ligaments

Aplasia of both cruciate ligaments is a rare congenital disorder. A 28-year-old male presented with pain and the feeling of instability of his right knee after trauma. The provided MRI and previous arthroscopy reports did not indicate any abnormalities except cruciate ligament tears. He was referred to us for reconstruction of both cruciate ligaments. The patient again underwent arthroscopy which revealed a hypoplasia of the medial trochlea and an extremely narrow intercondylar notch. The tibia revealed a missing anterior cruciate ligament (ACL) footprint and a single bump with a complete coverage with articular cartilage. There was no room for an ACL graft. A posterior cruciate ligament could not be identified. The procedure was ended since a ligament reconstruction did not appear reasonable. A significant notch plasty if not a partial resection of the condyles would have been necessary to implant a ligament graft. It is most likely that this would not lead to good knee stability. If the surgeon would have retrieved the contralateral hamstrings at the beginning of the planned ligament reconstruction a significant damage would have occurred to the patient. Even in seemingly clear diagnostic findings the arthroscopic surgeon should take this rare abdnormality into consideration and be familiar with the respective radiological findings. We refer the abnormal finding of only one tibial spine to as the "dromedar-sign" as opposed to the two (medial and a lateral) tibial spines in a normal knee. This may be used as a hint for aplasia of the cruciate ligaments.     

Total hip arthroplasty in juvenile rheumatoid arthritis. Two to eleven-year results

From 1971 to 1980, forty-five patients with juvenile rheumatoid arthritis had eighty-three cemented total hip replacements at The Hospital for Special Surgery and North Carolina Memorial Hospital. Thirty-four of these patients, with sixty-two involved hips, returned for examination and radiographs. The average age of these thirty-four patients at the time of surgery was twenty-six years, and twenty-seven of them, with forty-nine involved hips, were thirty years old or less. The average length of follow-up was six years (range, two to eleven years), with forty-one hips having been followed for five to eleven years. According to The Hospital for Special Surgery hip-rating system, thirty hips were rated excellent; nineteen, good; nine, fair; and four, poor. Of the four hips with a poor result, two (in the same patient) had severe heterotopic ossification with ankylosis postoperatively, and two had required revision: one for acetabular loosening six years after replacement and the other for a broken stem of the femoral component ten years postoperatively. Radiographic review of the sixty-two hips demonstrated progressive radiolucencies or migration of 26 per cent of the acetabular components and 8 per cent of the femoral components. The frequency of acetabular migration or progressive radiolucencies was related to the postoperative position of the component relative to the position of the true acetabulum. These results were somewhat better than those in other reports on cemented total hip replacement in young patients. The difference is probably related to the lower average weight and decreased activity level of patients with juvenile rheumatoid arthritis.