Uncemented Miller-Galante total knee replacement

Summary. Sixty-one primary uncemented Miller-Galante total knee replacements were implanted in 55 patients between June 1988 and December 1990. The results of routine radiological and clinical follow up carried out at an average of 1.3 years and 6.2 years after operation were used for evaluation. The Knee Society clinical score improved from 47.8 points before operation to 83.3 points one year after, and had progressed further to 87.6 points at the recent follow-up. The functional score improved from 45 points before operation to 75.23 points at early follow up, and 81.3 points at the recent review. Although radiological analysis showed that the femoral and tibial components overall were placed perpendicular to the mechanical axis of the limb, sufficient correction of the mechanical axis was not achieved to within ±10  mm deviation from the centre of the knee in 22 cases, with varus or valgus deformity remaining. No early or late infection occurred in this series. The uncemented Miller-Galante total knee replacement shows good biological fixation of both components. Wear of the metal-backed patellar and tibial polyethylene lead to a revision rate of 19% after 5 years.

---

Résumé. 61 prothèses totales de genou non cimentées de Miller-Galante (55 patients) ont été implantées entre Juin 88 et Décembre 90. Pour l’évaluation, ont été relevés les résultats des contr?les de routine radiologique et clinique, faits en moyenne 1,3 ans et 6,2 ans après l’intervention. L’évaluation clinique (échelle de la Knee Society) montre une augmentation à partir de 47,8 points pré-opératoires à 83,3 points 1 an après l’intervention et 87,6 points à l’évaluation récente. Le score fonctionnel (de la Knee Society) montre une augmentation à partir de 45 points à 75,23 points à 1 an et 81,3 points à l’évaluation récente. Les implants fémoraux et tibiaux ont toujours été correctement placés par rapport à l’axe mécanique du membre. Cependant la correction de l’axe mécanique n’a pas été suffisante dans 22 cas où persiste un varus ou un valgus. Il n’y a pas eu d’infection de relevée dans cette série. La prothèse sans ciment de Miller Galante a une bonne fixation biologique des deux composants. L’usure de la rotule et du plateau tibial sont la cause d’un taux de 19% de reprise après 5 ans.

---

---

Accepted: 9 January 1998     

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 anatomic graduated components posterior cruciate-retaining total knee replacement.

The purpose of the current study was to evaluate the authors' 15-year experience with the Anatomic Graduated Components total knee replacement. This is a report of the survivorship of 4583 Anatomic Graduated Component total knee arthroplasties. Kaplan-Meier survival analyses were performed with the end point defined as radiographic loosening, revision, or both. This end point was subdivided into the best case scenario in which it was assumed that all the patients lost to followup were doing well throughout the study and a worst case scenario in which it was assumed that all patients lost to followup had failed results at their last clinic visit. There were six (0.18%) femoral, 21 (0.46%) tibial, and 180 (4.2%) all-polyethylene patellar component failures secondary to aseptic loosening. All femoral components and 90% of the tibial components were revised; however, only 15 patellar components were revised. The clinical survival rate with revision of one or more of the components was 98.86% at 15 years. Despite having nearly flat-on-flat geometry and retaining the posterior cruciate ligament, which should increase the stresses in the polyethylene and at the bone-cement interface, this total knee replacement has proved to have minimal wear and excellent longevity with time. The authors think this is a result of the direct compression molded polyethylene articulation and the nonmodular configuration that incorporates metal backing on the tibial component and eliminates back-sided tibial component polyethylene wear.     

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 of cementless versus hybrid fixation for total knee arthroplasty.

In a prospective trial, 99 patients (100 knees) with osteoarthritis were randomized to either cementless or hybrid fixation of cruciate-retaining Miller-Galante-I total knee arthroplasties between January 1987 and December 1988. Thirty-one patients died during the study period and two additional patients were lost to followup, leaving 67 total knee arthroplasties for analysis. Thirty-nine patients underwent revision surgery at an average of 6.9 years postoperatively. The main reason for revision surgery was failure of metal-backed patellas with 25 knees revised at an average of 7.4 years, and the second most common reason was tibial polyethylene failure. Survival curves showed 60% survival at 14 years for all knees, and 85% survival at 14 years when failures for metal-backed patellas and infection were excluded, with no significant difference between the two groups. Failure of metal-backed patellas was significantly higher in the cementless group. Tibial polyethylene failure occurred in five of the hybrid group and none of the cementless group, but this was not a significant difference. Surviving prostheses were assessed at an average of 12.8 years (range, 11.5-13.5 years). Average clinical scores were 94.8 points preoperatively, and 143 points at the latest followup, with significantly higher scores in the hybrid group. Differences in outcome between the two groups were not sufficiently significant to recommend one method of fixation over another. With elimination of poor design features related to the patellofemoral articulation and thin tibial polyethylene, cruciate-retaining total knee arthroplasties can yield good durable results, whether cementless or hybrid fixation is used.     

Preliminary results of Miller-Galante uncemented total knee arthroplasty

From July 1984 through February 1986, a total of 46 knees were placed in 42 patients. The average age of all patients was 58 years (range, 32 to 68). Osteoarthritis was the diagnosis in 38 knees, traumatic arthritis in 5, and rheumatoid arthritis in 3. During follow up, averaging 3.6 years (range, 2.0 to 4.5), the total knee score based on a modified Hospital for Special Surgery knee rating scale improved from a preoperative average of 59 to 93 postoperatively. Radiographically, partial radiolucencies (less than 1 mm) were present in at least one view in 72% of the knees in which the interface was well visualized. No radiolucencies were progressive. Complications occurred mainly in the patellar components, as 17% of metal-backed uncemented patellae required revision to cemented non-metal backed components. There were no deep infections. The authors remain cautiously optimistic while awaiting long-term follow up.     

Long-term results of Geomedic total knee replacement

Seventy-one Geomedic total knee replacements were reviewed retrospectively at a maximum of eight and a half years. The prosthesis was found to be successful in its primary aim of relieving pain. However, there was an overall failure rate of 18.3%. Analysis of the results by an actuarial method allowed comparison with other prostheses. The factors involved in failure are discussed.     

Unicompartmental knee replacement. A minimum 15 year followup study.

One hundred forty Marmor cemented unicompartmental knee replacements were inserted in 103 patients between 1975 and 1982. Fifty-two patients were women and 51 were men. One hundred twenty-five were medial compartment knee replacements and 15 were lateral knee replacements. At minimum 15 year followup 34 patients with 48 knee replacements were living; only four patients with four knee replacements were lost to followup. Average preoperative and final followup Hospital for Special Surgery knee scores were 57 and 82 points, respectively for the knees of living patients. Average preoperative and final followup Knee Society clinical and Knee Society functional scores were 31 and 42, and 85 and 71 points, respectively. For all knees, 10.2% (14 knees) were revised [4.4% (six knees) for tibial loosening, 5.1% (seven knees) for disease progression, and .7% (one knee) for pain]. For patients living 15 years, 12.5% (six knees) were revised [2.1% (one knee) for tibial loosening, and 10.4% (five knees) for disease progression]. Revision for failure of fixation of these unicompartmental replacements was comparable with that reported for fixed bearing total knee replacement. Disease progression (46%; 62 of 136 knees) and tibial subsidence with wear (10.4%; 15 of 136 knees, five of which required revision) were the major long term problems in this group of patients.     

Surgical closing in total knee arthroplasty. A series followup

The benefits of closing the surgical wound of a primary and revision total knee prosthesis with the knee in full flexion are examined. A previous study showed that surgically closing the primary knee arthroplasty with the knee in full flexion produced significantly more postoperative flexion at 6 months: 114.7 degrees compared with 108.1 degrees. Of 108 selected sequential primary knee arthroplasties, the first 52 knees were closed surgically with the leg in full knee extension, and the second 56 knees were closed in 90 degrees to 110 degrees flexion, depending on the available motion of the joint. The patients in each group were matched closely in age, weight, height, gender, and surgical technique. At all followup intervals, the flexion measurements were significantly better in the flexion closure group. At 1 year, the flexion group had 117.9 degrees and the extension group had 112.9 degrees flexion. The revision series also was a selected sequential series with 13 knees in each closure group. In the revision case, the 1-year findings were similar, with significantly more knee flexion in the flexion closure group (118.7 degrees compared with 112.7 degrees). In matched groups, flexion closure in primary and revision knee replacements significantly increased total range of motion, as seen at the 1-year followup.     

A comparison of cemented and cementless fixation with the Miller-Galante total knee arthroplasty

This study demonstrates the comparability of cemented and cementless fixation in total knee arthroplasty at short-term follow-up. While some differences in pain, limp, and support were noted, knee scores were equivalent. Roentgenographic analysis as well as implant retrieval studies demonstrate that porous ingrowth is a viable method of fixation of total knee components. Further long-term follow-up studies will be required to determine both the long-term clinical results and the longevity of the fixation interface.     

Long-term results of primary total knee replacement in patients with hemophilia

BACKGROUND: The outcome of total knee replacement in patients with hemophilia has been variable. Several authors have suggested a relationship between high rates of late infection following total knee replacement in patients with hemophilia and a positive HIV status. The objective of this study was to evaluate the results of primary total knee replacements performed in a large group of hemophilic patients at a single institution by the same primary surgeon. METHODS: The results of ninety primary total knee replacements performed in sixty-eight hemophilic patients between 1975 and 2001 were reviewed retrospectively. The HIV status and the CD4 count at the time of the surgery were recorded for fifty-three patients (seventy-one knees). Knee Society clinical and functional scores were determined for twenty-nine patients (thirty-eight knees) who were available for follow-up. Prosthetic survival was calculated with use of Kaplan-Meier survivorship analysis. RESULTS: The overall prevalence of infection was 16%. Twelve knees required removal of components, and the reason for the removal was late infection in nine of them. The prevalence of infection in HIV-positive and HIV-negative patients was 17% and 13%, respectively (p = 0.5). When component removal for any reason, survival free of infection at any point, and mechanical failure were considered to be the end points, the ten-year survival rates were 83%, 77%, and 96%, respectively. The Knee Society clinical score was excellent or good for 80% of the knees, and the Knee Society functional score was excellent or good for 97% of the knees. CONCLUSIONS: Despite the anatomical challenges, the mechanical survival of total knee replacements in patients with hemophilia is quite good. However, the prevalence of infection after the total knee replacements was high. The prevention of late infection would substantially improve the long-term outcome of total knee replacements in this patient population.     

Total condylar knee replacement: a 20-year followup study.

Between 1976 and 1979, 220 total knee replacements were done on 164 patients using the Total Condylar Knee replacement. The diagnosis was rheumatoid arthritis in 111 knees and osteoarthritis in 109 knees. Patients with 157 knees are known to have died as of December 1998, leaving 63 knees in patients who are still alive. Twelve patients with 18 knees were lost to followup. The average 20-year followup data (range, 18-22 years) are presented for 45 knees in 30 patients using Knee Society evaluations. The average Knee Society clinical score for the surviving patients was 88 points, and the average functional score was 58 points. The radiographic followup averaged 19 years. The average overall alignment was 3 degrees valgus. Femoral lucencies were present in 17 of 40 adequate lateral views, most commonly about the anterior and posterior surfaces. Two femoral components were loose. Twenty-two tibial components had radiolucencies; four radiolucencies were circumferential. The remaining 41 knees retained a well-fixed cemented central peg despite proximal interface lucencies. From the group of 220 knees, 14 revisions have been done at an average of 11.4 years postoperative. Two knee replacements were revised for isolated tibial loosening, whereas one knee replacement had isolated femoral loosening. Three knee replacements were revised for loosening of both components, and one was revised for isolated patellar loosening. Four patients had sepsis develop; three of these four patients were treated with two-stage revision, and one underwent fusion. Three patients were treated for supracondylar fractures. The Total Condylar Knee replacement maintains excellent durability at 20-years followup.     

Long-term followup of the bone-ingrowth Ortholoc knee system without a metal-backed patella.

Between June 1981 and January 1984, 265 Ortholoc-I femoral and tibial components were implanted using bone-ingrowth technique in 202 patients. Five knees (five patients) were lost to followup and 66 knees were excluded because the patients died, leaving 184 knees (165 patients) with 15 to 18 years followup. One knee loosened during the 15- to 18-year followup period and was revised, and five knees were revised for infection. Survival rate at 18 years considering loosening was 98.6%. At 15 years after surgery, 79.9% of patients did not have pain, 10.1% had mild pain, 8% had moderate pain, and 2% had severe pain. At 18 years after surgery, 77.6% did not have pain, 7.2% had mild pain, 5.2% had moderate pain, and 1% had severe pain. Knee flexion was 110 degrees preoperatively and increased to a mean of 115 degrees at 2 years postoperative, then remained unchanged for the rest of the followup. Intramedullary alignment proved to be highly effective, and has become the standard for total knee arthroplasty instrumentation systems. Total knee replacement with bone-ingrowth technique was a reliable and effective means of treating the end-stage arthritic knee. In patients who required revision surgery, excellent bone stock remained and revision with bone-ingrowth technique was accomplished easily.     

Problems with cementless total knee arthroplasty at 11 years followup.

One hundred two patients with 131 consecutive cementless total knee arthroplasties that retained the posterior cruciate ligament were followed up prospectively. The average age of the patients was 58 years (range, 32-75 years). The mean followup on the surviving knee arthroplasties was 11 years (range, 7-16 years). The patellar component was metal-backed in the first 112 (85%) knees, cementless all-polyethylene in the last 17 (13%) knees, and two knees had a prior patellectomy. Forty-four metal-backed patellar components (48%) were revised; nine were loose, and 35 had polyethylene wear through. Thirteen femoral components (12%) were revised because of femoral abrasion from a failed metal-backed patellar component. No other femoral component was revised, loose, or had osteolysis develop. Nine (8%) tibial components had failure of ingrowth; eight have been revised. Partial radiolucencies occurred in 53% of the tibias. Thirteen (12%) small osteolytic lesions developed, all around screws or screw holes in the tibial components. At an average of 11 years followup, cementless fixation yielded mixed results: cementless femoral fixation was excellent and metal-backed patellar components had a 48% patellar revision rate. Cementless tibial components had an 8% aseptic loosening rate and a 12% incidence of small osteolytic lesions. Based on these results, the authors have abandoned cementless fixation in total knee arthroplasty.     

Kinematic total knee replacement

We reviewed 124 consecutive kinematic condylar total knee replacements (in ninety-one patients) at two to four years postoperatively. One hundred and eleven (90 per cent) were rated as good or excellent. The average active postoperative flexion was 106 degrees (range, 94 to 120 degrees). Twenty-two knees (18 per cent) had incomplete, non-progressive radiolucent lines, less than one millimeter in width, at the tibial bone-cement interface; these were considered insignificant. Restriction of stair-climbing ability in this series appeared to be a function of involvement of multiple joints rather than of patellar replacement, as the rheumatoid patients with resurfaced patellae performed the worst. The osteoarthritic patients with involvement of a single joint performed the best, regardless of whether the patella was resurfaced or not. When compared with a similar series of total knee replacements in which the tibial component was made entirely of plastic, less reaction at the bone-cement interface was found with the metal-backed kinematic tibial component. We suggest that this finding is clinical confirmation of in vitro studies that demonstrated the advantage of metal-backed tibial components. We concluded that this procedure, if meticulously performed, will give predictably good to excellent results with a low complication rate, a good postoperative range of motion, and a favorable-appearing bone-cement interface at two to four years.