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Contributors
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AmarS.Ranawat Department of Orthopedics, Hospital for Special Surgery, New York, NY,
USA
ranawatamar@hss.edu
XXI
MichaelD.Ries
riesm@orthosurg.ucsf.edu
Martin Roche
West Palm Beach, FL, USA
martin@mroche.com
Robert P. Runner
Rehabilitation Center, Downey, CA, USA
rrunner@dhs.lacounty.gov
Anas Saleh
Vero Beach, FL, USA
saleha3@ccf.org
HythamS.Salem
GiulioSanti School of Orthopaedic Surgery, Università degli Studi di Milano, Milano, Italy
giulio.santi@unimi.it
PabloSanz-Ruiz
Complutense University, Madrid, Spain
NanaO.Sarpong Department of Orthopedic Surgery, Columbia University Irving Medical
Center, New York, NY, USA
no2282@cumc.columbia.edu
Reno Orthopaedic Clinic, Reno, NV, USA
Hospital for Special Surgery Florida, Department of Orthopaedic Surgery,
Department of Orthopaedic Surgery, Rancho Los Amigos National
Department of Orthopaedic Surgery, Cleveland Clinic Indian River Hospital,
Northwell Health Orthopedics, Lenox Hill Hospital, New York, NY, USA
Orthopedic and Trauma Service, Marañon on General University Hospital,
AdamA. Sassoon
Santa Monica, CA, USA
Asassoon@mednet.ucla.edu
Axel Schmidt Service de Chirurgie Orthopedique, Aix-Marseille University, Hospital
Sainte-Marguerite, Marseille, France
IsaacSchultz Cleveland Clinic Florida, Levitetz Department of Orthopaedic Surgery, Cleve-
land Clinic Blvd, Weston, FL, USA
Ran Schwarzkopf Department of Orthopaedic Surgery, NYU Langone Health, NYU
Langone Orthopedic Hospital, New York, NY, USA
ran.schwarzkopf@nyulangone.org
TravisScudday
Orthopedic Specialty Institute, Irvine, CA, USA
tscudday@osiortho.com
PeterK.Sculco Hospital for Special Surgery, New York, NY, USA
SculcoP@hss.edu
ThomasP.Sculco Hospital for Special Surgery, New York, NY, USA
SculcoT@hss.edu
David Geffen School of Medicine, University of California Los Angeles,
Hoag Orthopedic Institute, Irvine, CA, USA
XXII
https://t.me/medicina_free
Contributors
AhmedSiddiqi Orthopedic Institute of Central Jersey, Manasquan, NJ, USA
MarkJ.Spangehl Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ,
USA
spangehl.mark@mayo.edu
BryanD.Springer
bryan.springer@orthocarolina.com
MatthewW.Squire
Medical Center, Aurora, IL, USA
orthosquire1@gmail.com
ThomasM.Steck
Angeles, CA, USA
thomas.steck@med.usc.edu
RussellPresleySwann
AtsushiTakahashi Joint Surgery, Sports Clinic Ishinomaki, Ishinomaki, Japan
a-takahashi@jss-clinic.com
JohnP.Taliaferro
VA, USA
JPT2SH@hscmail.mcc.virginia.edu
TimothyL.Tan
delphia, PA, USA
timothy.tan@rothmanortho.com
ThomasP.Vail
San Francisco, CA, USA
thomas.vail@ucsf.edu
, MD OrthoCarolina Hip & Knee Center, Charlotte, NC, USA
Rush Copley Center for Joint Preservation and Replacement, Rush Copley
Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los
Orthopedic Centers of Colorado, Denver, CO, USA
Department of Orthopaedic Surgery, University of Virginia, Charlottesville,
Department of Orthopaedic Surgery, Rothman Institute and Jefferson, Phila-
Department of Orthopaedic Surgery, University of California, San Francisco,
Craig Della Valle
Chicago, IL, USA
craig.dellavalle@rushortho.com
DriesVan Doninck Department of Orthopedic Surgery, University Hospitals Leuven, Leuven,
Belgium
FrankVerheyden Department of Orthopedic Surgery, H.Hart Hospital, Lier, Belgium
frank.verheyden@hhzhlier.be
Maarten Verheyden Department of Orthopedic Surgery, University Hospitals Leuven,
Leuven, Belgium
JesusM.Villa Cleveland Clinic Florida, Levitetz Department of Orthopaedic Surgery, Cleve-
land Clinic Blvd, Weston, FL, USA
villaj2@ccf.org
Wilson Wang Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine,
National University of Singapore, Singapore, Singapore
wilson_wang@nuhs.edu.sg
Department of Orthopaedic Surgery, Rush University Medical Center,
Contributors
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DerekWard San Francisco Department of Orthopaedic Surgery, University of California, San
Francisco, CA, USA
derek.ward@ucsf.edu
XXIII
AnnetteW-Dahl
Sweden
annette.w-dahl@med.lu.se
BenjaminM.Wooster
USA
benjamin.wooster@orthocarolina.com
Seid Mohammed Yasin
College, Addis Ababa, Ethiopia
PiersJ.Yates Orthopaedics WA, Murdoch and The Mount Private Hospitals, Orthopaedic
Research Foundation WA, Fiona Stanley and Fremantle Hospitals Group, University of Western Australia, Perth, WA, Australia
Simon W. Young Department of Orthopaedic Surgery, North Shore Hospital, Auckland,
New Zealand
Simon.young@auckland.ac.nz
MusaB. Zaid Department of Orthopaedic Surgery, University of California, San Francisco,
San Francisco, CA, USA
Musa.Zaid@ucsf.edu
YoavS.Zvi
yzvi@monteore.org
Department of Clinical Sciences Lund/Orthopedics, Lund University, Lund,
Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, NC,
Department of Orthopedic Surgery, Yekatit 12 Hospital Medical
Department of Orthopedic Surgery, Monteore Medical Center, Bronx, NY, USA
History
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Contents
Chapter 1 The History of Total Knee Arthroplasty – 3
Ioannis Gkiatas, Thomas P. Sculco, and Peter K. Sculco
1
I
The History ofTotal Knee
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Arthroplasty
IoannisGkiatas, ThomasP.Sculco, andPeterK.Sculco
Contents
1.1 Introduction – 4
1.2 First Attempts – 4
1.3 Early Attempts Using Metallic Prostheses toTreat Knee
Arthritis – 4
1.4 The Concept ofModern TKA – 5
1.5 Patella – 8
3
1
1.6 Mobile Bearing – 10
1.7 The Evolution ofAlignment Parameters: Anatomic Versus
Kinematic Versus Restricted Kinematic – 10
1.8 The Evolution ofFemoral Component Design – 10
1.9 The Evolution ofTibial Component Design – 11
1.10 The Evolution ofPolyethylene—The Growth ofMid-Level
Constraint – 11
1.11 The Evolution ofFixation inTKA – 12
1.12 Conclusion – 12
References – 13
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_1
4
I. Gkiatas et al.
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1.1 Introduction
1
Total knee arthroplasty (TKA) is one of the most commonly performed surgical procedures with the number
of TKAs nearly tripling in a 13-year period (Kurtz
2005). In 2020, approximately 1,065,000 TKAs will be
performed in the United States, and this number will
likely increase over time (Singh etal. 2019). The success
of TKA is based on excellent implant survivorship and
the alleviation of joint pain and improvement of function in the majority of patients.
The biomechanical principles and component materials that are used today were initially conceptualized
and developed in the early 1970s. While TKA in 2020 can
be performed in a multitude of ways—either manually
or robotically, with resection or retention of the ACL
and PCL, utilizing various (i.e., symmetric, asymmetric,
medial congruent, and ultracongruent) insert designs,
and adhering to mechanical or kinematic alignment
and plaster of Paris (Amendola etal. 2012). Despite the
great innovation of Gluck, the rst results were not
promising so other ideas and concepts continued to be
pursued such as the interposition of other tissues within
the knee joint (Heaton and Dorr 2003).
In 1886, Ollier described a procedure similar to
Verneuil’s with the use of muscle instead of joint capsule
(Murray 1991), and in 1894 Helferich presented successful
results in transforming an ankylosed knee to a functional
one using a resection arthroplasty and the use of muscle as
interposed tissue (Helferich 1894). The use of subcutaneous fat, fascia lata, and patellar fat pad by Murphy in 1913
(Murphy 1913), Putti in 1920 (Putti 1921), and Albee in
1928 (Albee 1928), respectively, did not prove to be ideal
materials nor the prepatellar bursa proposed by Cambel in
1921 (Campbell 1921). The other proposed alternatives
such as chromized pig bladder, cellophane, sheets of
nylon, and skin also did not prove effective (Baer 1918;
Samson 1949; Kuhns 1964; Brown etal. 1958).
priniciples—all of these modern practices can be traced
back to the engineers and orthopedic surgeons in the
1970s and 1980s. The purpose of this chapter is to highlight the key developments in the history of TKA design
1.3 Early Attempts Using Metallic
Prostheses toTreat Knee Arthritis
in order to shed light on more recent developments.
The rst metallic implants for knee replacement were
> The success and failures of the early period in TKA
design may also provide more information on the
risks and benets of more recently released designs
and support the adage “those who do not know history are doomed to repeat it!”
designed in 1937 and 2years later a vitallium interposition mold was placed over the femur in patients
(Campbell 1940). Some years later Smith-Petersen, who
had experience from hip arthroplasty, introduced a distal femur prosthesis for the knee made from vitallium
(Riley 1976). Lacheretz in 1952 (Lacheretz 1953) as well
Many international surgeons and engineers were
involved in this effort and today there has been a consensus on the condylar design of knee replacement in most
centers.
as Kraft and Levinthal in 1954 (Kraft and Levinthal
1954) implanted an acrylic distal femur prosthesis. At
Massachusetts General Hospital, orthopedic surgeons
reported a series of 78 cases using a modication of
Smith- Petersen arthroplasty but with poor results (Jones
etal. 1967). This prosthesis was a distal femoral implant
1.2 First Attempts
xed with an intramedullary femoral stem which tended
to erode the articulating cartilage and often created a
During the nineteenth century, the idea of treating knee
depression in the tibial plateau (Murray 1991).
arthritis with replacement materials was spawned and
MacIntosh & McKeever Tibial Plateau Design
initially took form as a soft tissue interposition between
the joint surfaces with or without bone resection of distal femur and proximal tibia (Amendola et al. 2012).
The rst attempts are reported in 1860 when Verneuil
(Verneuil 1860) proposed the interposition of soft tissues in order to reconstruct the articular surface of the
knee joint. One year later, Ferguson (Ferguson 1861)
attempted to eradicate the arthritic joint by resecting the
entire knee joint. The concept of prosthetic material
interposed in the arthritic knee joint was further evolved
in 1880. Implants made from ivory were described by
Thermestocles Gluck who proposed their stabilization
to bone using cement made from colophony, pumice,
z
MacIntosh in the late 1960s (MacIntosh 1958) introduced the idea of acrylic tibial plateau hemiarthroplasty
which was originally described by Jansen for the treatment of proximal tibia deformities (Murray 1991).
Another similar implant to the MacIntosh implant was
designed by McKeever (1960). Both of these implants
resulted in good early outcomes. These “hemiarthroplasties” were employed frequently in patients with rheumatoid arthritis and were semilunar in shape, came in
multiple sizes, were made of cobalt chrome, and were
placed over the medial and lateral tibial plateau
(. Fig.1.1).
The History ofTotal Knee Arthroplasty
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. Fig. 1.1 The MacIntosh & McKeever tibial plateau design.
(Orthobullets—free learning and collaboration community for phy-
7 www. orthobullets. com)
sicians,
Hinged Total Knee Implants
z
Hinge prosthetic devices were popularized rst in
Europe. An experimental hinged total knee implant was
initially proposed by Judet etal. (1947), and the early
results at 2years with this prosthesis were rst reported
in 1949 by Magnoni and d’ Intignano (Magnoni and
d’Intignano 1949). The hinged acrylic prostheses were
modied and fabricated into metal implants by Walldius
(1953). This implant was a xed axis hinge, had several
sizes, was somewhat bulky (Shiers 1954; YOUNG 1963),
and became widely accepted in Europe and particularly
in Scandinavia.
Guepar Hinged Prosthesis
z
Using the experience with the Walldius prosthesis,
another xed-axis hinge, the Guepar hinged prosthesis,
was developed in the 1970s by a consortium of designers
primarily from France (Ranawat and Sculco 1985). This
implant was also used in the United States in cases of
severe deformity with marked ligamentous insufciency.
The early results with the Guepar were excellent, but
failures eventually occurred primarily with implant
loosening and migration due to the xed axis nature of
the implant and the severe torsion loads at the intramedullary bone–cement interface (Hoikka et al.
1989)
(. Fig.1.2).
5
Hospital) knee arthroplasty (. Fig.1.3). This knee had
a “roller and trough” design and the cruciate ligaments
could be sacriced. The contact area for the components
was quite extensive in an attempt to reduce focal loading
and wear. The concept of soft tissue balancing was also
derived from this collaboration where ligament asymmetry was dealt with by releasing the tight ligament on
the concave side of the deformity and this was balanced
with the lax ligament on the convex side of the deformity.
> This concept was pivotal to subsequent knee design
and success and is still utilized today.
The publication by Todd, Freeman, and Sculco documented this technique for the rst time and it was presented at the AAOS in 1974 (Freeman etal. 1973, 1977).
As knee replacement design evolved, all components at
this time consisted of a polyethylene component on the
tibial side mated with a metal femoral component. All
components were xed with methylmethacrylate cement
popularized by John Charnley in hip arthroplasty. Tibial xation of the polyethylene was enhanced by ns,
grooves, slots, or other shallow irregularities on the
undersurface of the prosthesis.
1.4 The Concept ofModern TKA
During the early evolution of total knee replacement
design, there existed a strong debate about whether the
femoral and tibial components should be monoblock or
unicondylar (and individually resurface each femoral
condyle and each tibial plateau surface with an implant).
The Polycentric Knee
z
Gunston who had visited Charnley and discussed knee
replacement design with him was a strong proponent of
individual components, and this evolved into the
Polycentric knee (Gunston 2006) (. Fig. 1.4). The
Polycentric knee had four individual components which
were quite narrow and t into grooves on the femoral
and tibial surfaces. The technique was difcult and there
was little stability inherent in this device leading to component subsidence, dislocation of the individual components, and eventual failure.
1
Freeman–Swanson TKA Design
z
One of the rst successful collaborations of a bioengineer and orthopedic surgeon occurred in London in the
late 1960s. Alfred Swanson of the Imperial College, a
brilliant engineer, and Michael Freeman, a master innovative hip and knee surgeon, designed a unique knee
implant known as the ICLH (Imperial College London
The Duocondylar Prosthesis
z
Developed in 1971, the Duocondylar prosthesis from
the Hospital for Special Surgery had a bridged monoblock condylar design with two thin femoral condylar
surfaces (. Fig. 1.5). This Duocondylar design consisted of a at, high-density polyethylene tibial plateau,
which was in two parts, whereas the femoral component
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I. Gkiatas et al.
1
a b
. Fig. 1.2 a The Walldius prosthesis (Orthobullets—free learning and collaboration community for physicians, 7 www. orthobullets. com).
b The Guepar prosthesis. (From leNobel and Patterson 1981. © The British Editorial Society of Bone and Joint Surgery, with permission)
had a metal bridge connecting the two thin metallic condyles. The patellofemoral joint remained unresurfaced
(Ranawat and Sculco 1985). This implant was one of the
rst to be introduced with instrumentation for improved
alignment although very rudimentary (Heaton and
Dorr 2003). Both cruciate ligaments had to be preserved
with the Duocondylar knee and this increased its failure
rate especially in knees with severe deformity and inammatory arthritis with ligamentous damage. The design
of this implant was later modied in order to include a
polyethylene patellar replacement which was named the
Duopatellar prosthesis (Ranawat and Ranawat 2012).
The Total Condylar Prosthesis
z
A major breakthrough in implant design occurred when
the total condylar (TC) prosthesis was introduced in
1974 and this was adopted quickly worldwide and
became the design platform for future knee implant
development (. Fig.1.6). It was again a collaboration
between a biomechanical engineer, Peter Walker, an
The History ofTotal Knee Arthroplasty
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. Fig. 1.3 The Freeman–Swanson TKA design. (Reprinted from
(Insall and Scott 2018), © 2018, with permission from Elsevier)
7
. Fig. 1.5 The Duocondylar prosthesis. (Reprinted from Insall and
Scott 2018, © 2018, with permission from Elsevier)
1
. Fig. 1.4 The Polycentric knee designed by Gunston. (From Gun-
ston 2006, by courtesy of Wolters Kluwer Health, Inc.)
innovative designer, and Drs. John Insall and Chitranjan
Ranawat, surgeons at the Hospital for Special Surgery
(HSS) in NewYork City. The fundamental concept was
the replacement of all three components of the knee
with a single tibial all-polyethylene component. Both
cruciate ligaments were sacriced and knee stability was
achieved with the deep dish design of the polyethylene
tibial component and increased congruence with the
femoral component. A dome-shaped, single-lugged,
polyethylene component was generally also used with
this component.
The Insall–Burstein TKA Prosthesis
z
In 1978, Dr. John Insall in collaboration with the bioengineer Albert Burstein designed the posterior stabilized
(PS) TKA at HSS which was called the Insall–Burstein
knee (IB). The IB design included a cam-post mechanism and an all-polyethylene tibia and later a metal tib-
. Fig. 1.6 The total condylar prosthesis. (Parcells and Tria 2016,
courtesy of the U.S.National Library of Medicine)
ial tray to more evenly distribute tibial load. The IB II
implant was developed several years later and offered
modularity with a tibial component that engaged the
metal tray and a locking clip. This allowed changing the
8
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I. Gkiatas et al.
polyethylene if needed rather than having to remove the
1
entire tibial component. This implant was extremely
successful and formed the basis for subsequent posterior
stabilized designs (. Fig.1.7). A patellar polyethylene
component was generally used in all cases in the IB systems.
1.5 Patella
Patellectomy was commonly performed in the early treatment for severe patellofemoral arthritis (Murray 1991).
In 1955, McKeever designed a patellar implant which
was a metallic prosthesis tted to the patella with a screw
(McKeever 1955) (. Fig.1.9). In 1989, Insall designed a
Press-Fit Condylar Prosthesis and Porous-Coated
z
Anatomic Prosthesis
A group of Boston surgeons led by Drs. Richard Scott
and Thomas Thornhill used the same concepts but
believed in the preservation of the posterior cruciate
ligament, and this philosophy led to the development of
the press-t condylar (PFC) design (Depuy Synthes,
Warsaw, Indiana). In the early 1980s, David Hungerford
and Kenneth Krackow developed the porous-coated
anatomic (PCA) cruciate-retaining knee which was also
a condylar design. They popularized the concept of anatomic placement of the tibial component in approximately 3° varus which has seen a resurgence of interest
by surgeons interested in the kinematic philosophy of
metal button that was cemented into the resected arthritic
patella (Insall etal. 1980). This implant was used primarily for isolated patellofemoral arthritis but was abandoned after poor results in many patients (Insall 1982).
Later, metal-backed patellar implants were used in total
knee replacement, however, their results were inferior
mainly due to the reduced thickness of the polyethylene,
which resulted in polyethylene wear through, fracture of
the polyethylene, and separation of the polyethylene
from the metal backing (Andersen et al. 1991). As a
result of these failures, most current patellar implants are
all polyethylene designs, although more recently, good
early outcomes have been observed with uncemented
patella buttons with highly cross- linked polyethylene.
knee replacement. These surgeons are often credited for
the development of modern surgical instrumentation to
make implantation more reproducible (.
> In 1976, the rst constrained condylar TKA, the TC
III, was designed with an elevated and widened tibial
eminence for improved joint stability in knees with
severe deformity and marked ligamentous laxity and
for the growing demand for revision total knee
replacement (Ranawat and Ranawat 2012).
Fig.1.8).
Concept of Posterior Cruciate Ligament Preservation
z
> In the early 1970s, Yamamoto and Kodoma reported
the rst implantation of a uncemented condylar cru-
ciate-sparing prosthesis (Kodama–Yamamoto pros-
thesis) (Yamamoto 1979).
Other surgeons such as Scott, Thornhill, Hungerford,
and Krackow also supported the concept of trying to
abc
. Fig. 1.7 a The Insall–Burstein TKA prosthesis. b, c The Insall–Burstein II TKA prosthesis. (Reprinted from Insall and Scott 2018, ©
2018, with permission from Elsevier)
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