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D. N. Bracey and D. A. Dennis
30
. Fig. 30.11 a, b Rotating platform bearing “spin-out.” a The RP
bearing maintains articular congruity with the femoral component.
b A RP knee can experience bearing dislocation or “spin-out” with
tact stresses were not increased with internal rotation of
the one mobile-bearing design tested (NexGen LPS Flex
Mobile TKA; Zimmer Biomet, Warsaw, IN) suggesting
that mobile bearings are protective against this cam–
post wear pattern. Zingde et al. studied cam–post
mechanics by performing an invivo uoroscopic analysis of xed-bearing and MBPS TKA (Zingde et al.
2014). The authors found that cam–post engagement
was located more centrally in rotating platform designs
axial rotation during knee exion, most commonly where the posterolateral aspect of the polyethylene goes posterior to the lateral
femoral condyle
versus more eccentric cam–post contact in xed-bearing
designs (. Fig.30.13).
Self-alignment of the polyethylene bearing with the
femoral component reduces cross shear stresses on the
bearing by decoupling the multidirectional motion patterns (rotational, translational, and exion–extension)
present in FB TKA to unidirectional motion in MB
TKA which occurs at two different interfaces (exion–
extension on the superior aspect of the bearing and rota-
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. Fig. 30.12 Internal rotation of the tibial tray alters the cam–
post- contact area, effectively decreasing contact area which was
found to signicantly increase contact stresses. Additionally, this
leads to post impingement (arrow), accelerated wear, and risk of failure (From Nakayama etal. (2005). © The British Editorial Society
of Bone and Joint Surgery, with permission)
tion occurring on the inferior surface). Multidirectional
motion increases shear forces and accelerates wear as
compared with unidirectional motion (Jones etal. 1999;
Bragdon etal. 1996). More specically, simulator data
has shown polyethylene to have a lower coefcient of
friction when loaded with unidirectional motion which
results in lower wear rates (Pooley and Tabor 1972;
Abdelgaied etal. 2013). This likely explains why mobilebearing inserts have been shown to have equivalent or
lower wear rates compared to xed-
bearing inserts
despite having an additional bearing surface (Jones etal.
1999; Lu et al. 2010; Engh et al. 2009; McEwen etal.
2001, 2005; Delport etal. 2010; Fisher etal. 2004, 2006,
2010; Bragdon etal. 1996).
> The uncoupling of rotational strain transmission
from the implant to xation interface has been shown
to lessen xation stresses.
Bottlang etal. compared strains transmitted to the proximal tibia in cadavers implanted with xed and MB
TKA designs and found 33% less compressive strain and
68–73% less torsional strain with MB TKA (Bottlang
etal. 2006). Malinzak et al. compared the mechanical
response of the tibia to femoral component rotation in
349
30
composite tibia specimens implanted with primary and
revision xed-bearing or mobile-bearing components in
an effort to study the relationship between constraint
and force transmission to proximal tibia (Malinzak
et al. 2014). Using digital image correlation mapping,
the authors found that xed-bearing designs exerted
13.8x greater torque and 69% greater cortical strain on
the proximal tibia than RP designs (.
Fig.30.14).
Reducing stress at the xation interface should lower
the risk of xation failure and component loosening.
Despite these theoretical advantages with mobilebearing design, registry data has not proven
mobile- bearing design to have lower aseptic loosening
rates compared to xed-bearing design in primary TKA
(Gothesen et al. 2017). Differences in bearing design
may be more relevant in settings that require the use of
highly constrained constructs, such as revision TKA
where signicant bone loss may be encountered in addition to disrupted ligaments or unbalanced soft tissues.
Increasing constraint helps address ligament imbalance at the price of increasing stress on component xation to bone that may already be compromised from
osteolysis or implant removal in the revision setting
(Mow and Wiedel
1998; Peters etal. 1997; Rand 1991).
Failure after revision TKA is most frequently caused by
infection, but aseptic loosening is commonly cited as the
second most common mode of failure, accounting for
4.9–42% of failures (Rosso et al. 2019; Suarez et al.
2008; Siqueira etal. 2014; Mortazavi etal. 2011; Agarwal
et al. 2019). A mobile-bearing interface can decrease
implant xation stress and reduce the risk of aseptic
loosening after revision TKA.
We previously reported our own midterm clinical
and radiographic results of 280 revision TKAs performed with a mobile-bearing revision TKA system
(Kim et al. 2017). At a mean follow-up duration of
59.9 months, 4 cases failed due to aseptic loosening
(1.4%). More recently, Reina etal. reported on 367 revision TKAs with a mean 4-year follow-up duration using
a varus–valgus constrained implant (Sigma TC3
Rotating-
Platform) (Reina etal. 2019). The incidence of
failure due to aseptic loosening was 3%. The same institution also published long-term results after revision
TKA with rotating-hinge prostheses, an implant design
that has historically, resulted in high failure rates in
xed-bearing hinge designs secondary to aseptic loosening (Cottino etal. 2017). Cumulative incidence of revision for aseptic loosening at 10 years was surprisingly
low at 4.5%.
> The authors attributed this low incidence largely to
the mobile-bearing design reducing xation interface
stress but also to the benets of enhanced metaphyseal xation associated with the use of metaphyseal
sleeves.
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350
D. N. Bracey and D. A. Dennis
a
b
. Fig. 30.13 In vivo kinematic study of cam–post engagement pat-
terns with xed-bearing a and mobile-bearing b PS TKA designs
identied where the cam engages on the posterior aspect of the polyethylene post. Axial rotation of the rotating platform polyethylene
bearing keeps the cam and post nearly parallel throughout range of
motion to allow more central engagement on the post, while xedbearing knees engaged the medial aspect of the post. (Zingde et al.
2014; Greenwald and Heim 2005, with permission from Wolters Klu-
wer Health, Inc.)
Patellar tracking is also improved in MB TKA as
axial rotation of the polyethylene helps centralize the
extensor mechanism. With FB TKA, any internal rotation of the tibial tray will lateralize the tubercle and
extensor mechanism which can lead to maltracking or
even lateral subluxation of the patella (.
Fig. 30.10)
(Yang etal. 2008).
RP designs can accommodate mismatches in rotation of the tibial tray through self-alignment of the
bearing. At our institution, we retrospectively reviewed
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ab cd
ef gh
30
. Fig. 30.14 Digital image correlation mapping of the torsion-
induced von Mises strain response in the proximal tibia following
10° femoral external rotation in specimens implanted with xed-
1318 consecutive primary TKAs performed with PFC
Sigma PS implants (Depuy Synthes; Warsaw, IN) using
mobile (n= 940) or xed-bearing (n =378) inserts, to
assess the incidence of lateral retinacular release (LRR)
required to achieve perfect patellar tracking assessed
using the rule of “no thumb” (Yang et al. 2008). LRR
FB TKAs was 14.3% compared to 5.3% with MB TKA
(p<0.0001) lending further evidence to improved patellar kinematics with mobile-bearing design. Sawaguchi
etal. performed an invivo evaluation of 66 PS TKAs
using computer navigation, analyzing patellar tracking
and contact stresses with both xed- and mobile- bearing
inserts (Sawaguchi etal. 2010). They observed superior
patellar tracking and lower contact stresses in the MB
cohort. Despite other studies nding similar results supporting improved patellar kinematics with MB TKA
(Rees etal. 2005), Pagnano etal. (2004) did not nd differences in LRR or clinical outcome measures at both
3months and 1year in a comparative study of FB versus MB TKAs.
Previous kinematic studies have documented axial
rotation on the under-surface of the mobile-bearing
against the tibial tray, but the question remained if this
rotational freedom was preserved over time as the soft
bearing a–d or rotating platform components e–h (Malinzak et al.
2014 (2014), with permission from Elsevier)
tissues may encapsulate the bearing. Assessment of
long-term bearing mobility has been done during invivo
uoroscopic studies in which tantalum beads were
embedded within the bearing to determine if bearing
mobility is present. Analyses at 3 and 15months, 5years,
and nally at 10years demonstrated bearing mobility
was maintained over a 10-year period (Dennis et al.
2005; LaCour etal. 2014).
30.6 Clinical Outcomes After Mobile Versus
Fixed-Bearing TKA
TKA is a reliable surgery for the treatment of advanced
osteoarthritis, and pooled registry data indicate that
82% of TKAs last 25years (Evans etal. 2019).
> Despite the theoretical advantages of mobile-bearing
design that we present, comparative outcomes studies
against xed-bearing design have produced similar
clinical results in registries and trials with up to
15-year follow-up duration (Capella etal. 2016; Post
etal. 2010; Heckmann etal. 2019; Namba etal. 2011).
352
D. N. Bracey and D. A. Dennis
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. Table 30.1 Cumulative percent revision of primary total knee replacement by bearing mobility (Primary Diagnosis OA)
(Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)) (2019)
Bearing mobility N revised N total 1year 3years 5years 10years 15years 18years
30
Fixed 18,044 515,200 1.0
(1.0, 1.0)
Mobile 6671 127,815 1.2
(1.1, 1.3)
Total 24,715 643,015
OA osteoarthritis
Note: Excludes 186 procedures with unknown bearing mobility
Mobile-bearing implants have good survivorship in
meta-analyses with reliable clinical outcomes. Carothers
etal. performed a meta-analysis of 3506MB TKAs at
an average follow-up duration of 8.6 years (Carothers
et al. 2011). 15-year survivorship of rotating platform
designs (96.4%) was greater than meniscal bearing
implants (86.5%). Mean component loosening (0.33%)
and bearing instability (<1%) for all subgroups were
uncommon. Implants placed prior to 1995 exhibited
higher rates of bearing complications (1.6% vs. 0.1%),
believed due to improvements in gap balancing techniques in later years of the analysis. A recent prospective
20-year analysis of a single surgeon’s mobile-bearing
experience produced similar results (Milligan et al.
2019). In a cohort of 487 RP TKAs (DePuy LCS), 139
patients had a 20-year follow-up with cumulative survivorship of 98%.
However, other authors have cited that most clinical
studies supporting mobile-bearing technology have been
smaller-scale single-center reports (Namba etal. 2011),
while the majority of registry studies have failed to identify any difference in clinical outcomes with MB versus
FB TKA.Registry-based comparative data has shown
cumulative revision rates to be higher with use of MB
TKA (.
Table 30.1) (Gøthesen et al. 2013, 2017;
Namba etal. 2013; Jorgensen etal. 2019). These reports
typically include all different designs of MB TKA analyzed collectively. In vivo uoroscopic studies have demonstrated variable kinematic patterns based on the
design of the MB TKA (Dennis et al. 1998a, 2003a).
Similarly, clinical survivorship has varied based on
implant design. For example, rotating platform designs
have exhibited superior results when compared with
meniscal bearing implants (Carothers etal. 2011). The
senior author believes improved gap balancing surgical
technique development over the last two decades will
improve long-term results of MB TKA since these
designs are less forgiving (than FB TKA) of imperfect
gap balance due to the risk of bearing instability.
2.5
(2.4, 2.5)
3.4
(3.2, 3.5)
z
3.3
(3.2, 3.3)
4.5
(4.4, 4.6)
Conclusion
5.0
(4.9, 5.1)
6.3
(6.2, 6.5)
7.1
(6.9, 7.2)
8.3
(8.0, 8.5)
8.3
(7.9, 8.6)
9.6
(9.1, 10.2)
TKA-bearing design signicantly inuences knee kinematics and polyethylene wear properties. Registry studies reect the limited use of mobile-bearing designs both
in the United States and abroad, but critical advantages
are seen with mobile-bearing use compared to xedbearing design. With axial rotation in knee exion, the
mobile-bearing design increases contact area between
the femur and tibia, and effectively reduces contact
stress on the polyethylene bearing. Axial rotation of the
mobile-bearing on the tibial tray uncouples rotational
strain between the implant and xation interface at the
bone which is critical to reducing aseptic loosening with
use of highly constrained TKA constructs. The rotating
bearing also allows the extensor mechanism to autocentralize into the trochlear groove of the femoral component which improves patellar tracking and leads to
improved kinematic indices, reduced patellofemoral
contact stresses, and in our experience, signicantly
lower lateral retinacular release rates.
Proposed risks with mobile-bearing design use have
historically included increased polyethylene wear associated with the second articulating surface on the backside of the polyethylene, and also mobile-bearing
dislocation, termed “spin-out.” Retrieval analyses have
shown decreased volumetric polyethylene wear with
mobile- bearing designs over time, and bearing spin-out
has rarely been reported in TKAs done with appropriate
gap balancing techniques.
Despite the reported advantages with mobile- bearing
design, registry data has shown equivalent clinical outcomes and survivorship with xed- and mobile-bearing
designs. While it is possible that subgroup analysis of
the mobile-bearing design (rotating platform, meniscal
bearing, specic implant system) may show differences,
that data has been limited to smaller single-center studies. The senior author has seen improved clinical outcomes in his practice with use of a mobile-bearing
design. Surgeons should be aware of the advantages
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associated with mobile-bearing design use, but ultimately should implant the bearing design they feel most
comfortable with.
Take-Home Messages
5 Key elements to effective cementation tech-
nique include the following:
– Preparing a dry bony surface devoid of
marrow/blood lipid contamination
– Pressurization of the tibial surface
periphery due to cement escape
– Repeated evacuation of lipid-rich liquid
expelled by pressurization
– Removing cement in large fragments to
minimize generation of third body
debris particles
– Avoidance of micromotion during
cement curation to preserve xation
strength
5 MB TKA designs increase the femoral–tib-
ial contact area relative to FB TKA which
lowers contact pressures and reduces polyethylene wear.
5 Axial freedom of the polyethylene bearing
allows the component to self-align with the
femoral component which centralizes the
extensor mechanism and improves patellar
tracking.
5 Concerns of mobile-bearing spin-out/dislo-
cation have been minimized by precise gap
balancing surgical techniques.
5 MB TKA designs uncouple force transmis-
sion to the component xation interface.
This should be considered in settings with
impaired bone stock, such as revision TKA
where highly constrained components with
high xation stresses are utilized.
5 Registry data have failed to demonstrate
superior implant survivorship associated
with mobile- bearing use. Ultimately, surgeon preference and judgment are required
to pick the best bearing design for their
patients.
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357
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All-Polyethylene Tibial
Components inPrimary Total
Knee Arthroplasty: Why It
Works andWhy IDo Not Use It
Anymore?
AhmedSiddiqi, AbdullahAftab, andAmarS.Ranawat
Contents
31.1 Introduction – 358
31
31.2 Case Example – 358
31.3 Background – 358
31.4 Surgical Technique – 359
31.5 Implant Cost – 360
31.6 Clinical Outcomes – 360
References – 362
© 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_31
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