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The History ofTotal Knee Arthroplasty
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a b
. Fig. 1.8 a Porous-coated anatomic prosthesis. b Press-t condylar prosthesis. (From Heaton and Dorr 2003, by courtesy of Wolters Klu-
wer Health, Inc.)
1
. Fig. 1.9 The insertion of the cemented metallic patellar implant
with a screw. (McKeever 1955)
preserve the posterior cruciate ligament (Waugh etal.
1973; Townley and Hill 1974). The posterior cruciate
retraining implants generally had a horseshoe tibial
component to allow preservation of ligament insertion.
Cloutier from Canada advocated preserving both cruciate ligaments and the polyethylene component had to be
modular or have a larger central opening to preserve both
ligaments (Amendola etal. 2012) (. Fig.1.10).
The difculty with posterior cruciate preservation
(and ACL if also preserved) has always been the proper
balancing of this ligament to prevent posterior tethering
of the joint by a tight cruciate and thereby increased
posterior polyethylene wear and potentially reduced
knee exion. Additionally, if the cruciate is too tight, the
kinematics of the knee will be altered and femoral roll-
. Fig. 1.10 Prosthesis which allows the preservation of both cruci-
ate ligaments. (From Cloutier etal. 1999, by courtesy of Wolters
Kluwer Health, Inc.)
back may be less predictable than in a posterior cruciate
substituting design where it is controlled via the campost mechanism.
The rationale for posterior cruciate preservation was
that despite the wide success of the TC, PCL sacricing
prosthesis, there remained a concern of “paradoxical”
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anterior translation of the femoral component on the
1
tibia particularly during exion (Amendola etal. 2012)
because of the absent posterior cruciate ligament.
Additionally, there was a signicant reduction in range
of motion with reported average exion of 90° in a series
of 220 patients (Insall etal. 1979). Over the years, the
evolution of posterior stabilized implants design with
improved cam and post mechanisms that simulate PCL
function led to more predictable femoral rollback and
offered a greater range of motion, less wear, and lower
contact pressures (Dall’Oca etal. 2017).
1.6 Mobile Bearing
In most early total knee designs, wear of the polyethylene was a major concern that could compromise the longevity and function of the replacement.
Oxford Knee and LCS Knee Replacement System
z
The concept of mobile-bearing components was rst
introduced by Goodfellow and O’Connor in 1976 in
order to decrease focal polyethylene loading and hopefully reduce polyethylene wear. They designed a bicondylar knee prosthesis known as the Oxford knee in which
the polyethylene bearing freely moved on the metal tibial
tray (Goodfellow and O’Connor 1978). This mobile
polyethylene insert was called a “mensical bearing”
design and the congruency of the insert with the femoral
component imitated the medial compartment and associated mensical congruency in the native knee (Heaton and
Dorr 2003). The Oxford knee was used primarily in
Europe whereas in the United States, a new design, the
New Jersey Low-Contact-Stress (LCS) Knee Replacement
System (Depuy Synthes), was developed by Buechel and
Pappas in 1977. This implant was designed to resist the
dislocation of the meniscal bearing by using decreasing
radii of curvature on the posterior femoral side and by
controlling the movement of the bearing in dovetail
tracks on the tibial platform (Buechel and Pappas 1986).
has been reported that despite outstanding long-term
implant survivorship with mechanical alignment,
patient dissatisfaction may be as high as 20% (Baker
et al. 2007; Bourne et al. 2010). Technical options to
improve satisfaction include variation in alignment such
as the following:
5 The anatomic
5 The kinematic
5 The restricted anatomic
Anatomic alignment was introduced by Hungerford
and Krackow (1985) in order to potentially better replicate native knee kinematics and reduce patient dissatisfaction after TKA. In addition, maintaining the
anatomic oblique and parallel joint line between femur
and tibial articulations theoretically allows for better
load distribution on the tibial component and provides
better patella biomechanics as it reduced lateral retinacular ligament stretching during knee exes (Klatt etal.
2008; Ghosh etal. 2009). This alignment was popular
early after its introduction. Errors in alignment, particularly of the tibial component with excessive varus, led to
increased polyethylene wear and implant failure and
ultimately led to its falling out of favor as a mechanical
alignment target (Oussedik etal. 2020).
Contemporary principles behind kinematic alignment can be characterized as an evolution of anatomical
alignment as both are based on restoring a patient’s
native alignment with the placement of tibial and femoral components to match the pre-arthritic state (Howell
et al. 2013). The debate continues whether kinematic
alignment negatively impacts knee biomechanics and
long-term implant survivorship. For this reason, some
surgeons advocate “restricted” kinematic alignment in
which alignment boundaries for both the tibia and
femur are set (i.e., 3° varus or tibia and 3° valgus for
femur). The long-term survivorship and functional outcomes compared to mechanical alignment (as advocated
by Insall) continue to be debated (Oussedik etal. 2020;
Howell etal. 2013).
> Mobile bearing designs are less popular than xed
bearing knees as polyethylene wear has been less of a
problem in newer designs and the mobile bearing
knee tended to be somewhat less stable and harder to
balance.
1.7 The Evolution ofAlignment
Parameters: Anatomic Versus
Kinematic Versus Restricted Kinematic
As knee replacement design progressed, alternative
alignment techniques have been proposed in order to
improve the functional outcomes (Rivière etal. 2017). It
1.8 The Evolution ofFemoral Component
Design
The development of the condylar-resurfacing TKA
design arose from two different concepts, allowing the
prosthesis to determine the knee kinematics (posterior
stabilized) concept or to preserve posterior cruciate ligament and allow the retained soft tissue to inuence knee
kinematics. Each philosophy continues to have its proponents and critics. The early condylar designs were
PCL sacricing but not did adequately substitute PCL
function which led to unreliable femoral rollback on the
tibia and often allowed anterior translation as the knee
The History ofTotal Knee Arthroplasty
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1
exed (Dall’Oca etal. 2017). Resultant increased polyethylene wear may have also resulted in these early TC
designs (Robinson 2005). In addition, the absence of
“rollback” resulted in impingement of the posterior
femoral metaphysis against the tibial articular surface at
approximately 95° of exion. This along with other
design issues (such as limited sizing) likely led to the
restriction of motion in the early condylar designs.
> To correct these issues, the posterior cruciate-
substituting design was developed in 1978 by adding a
central cam mechanism to the articular surface geometry of the total condylar prosthesis.
The cam on the femoral component engaged a central
post on the tibial articular surface at approximately 70° of
exion and caused the contact point of the femorotibial
articulation to be posteriorly displaced, effecting femoral
rollback and allowing further exion (Causero etal. 2014).
1.9 The Evolution ofTibial Component
Design
The initial tibial component had a metaphyseal stem in
order to resist varus–valgus forces of the prosthesis during asymmetrical loading. It was all-polyethylene and
later metal backing was added. This alteration allowed
more uniform stress transfer to the underlying cancellous
metaphyseal bone and additionally protected the polyethylene from deformation (Causero etal. 2014). Separate
tibial plateau components were abandoned for one piece
units early in knee replacement development (Causero
etal. 2014). However, while the metal backing improved
load distribution in the tibial metaphysis, modularity
introduced another interface, the concept of backside
wear. The PFC design (DePuy Synthes, Warsaw IN) and
other similar locking mechanism designs demonstrated
increased backside wear, polyethylene particles that led
to large amounts on osteolysis in some cases. Despite
inferior loading characteristics, several studies have demonstrated excellent long-term survivorship with all-polyethylene tibias and they continue to be used today.
kinematics. The PS design was a modication of the earlier total condylar design which was lax mainly in exion.
> The liner in a PS prosthesis, where both cruciate liga-
ments are sacriced, has a post, which engages the
femoral cam at approximately 40–90° of exion. In
contrast to PS liners, CR polyethylene liners, where
the PCL should be retained, do not have the central
post and are typically at.
They are also required to guide the knee through the
range of motion and provide appropriate stability in all
planes. The newer ultracongruent designs aim to prevent
the paradoxical anterior translation of the femur that
takes place in some CR designs. The PCL can be retained
or sacriced but typically is sacriced.
> In the 1990s, medial pivot liners were designed and
developed to simulate knee kinematics. The medial
compartment is deeper and keeps the medial femoral
condyle relatively stable as a “pivot point,” and the
lateral compartment is atter allowing for some natu-
ral translation via the “screw home” mechanism
(Macheras etal. 2017).
The evolution of polyethylene constraint has progressed through several iterations. The original TC knee
had a dishing of the plateau surface to improve congruency and provide some stability in a knee that sacriced
both cruciate ligaments. The posterior cruciate ligamentretaining knees tend to be at on their surfaces to allow
posterior rollback with an intact posterior cruciate ligament controlling the knee kinematics. Asymmetric posterior loading tended to be increased in the at designs
and, therefore, increased congruency and dishing are
favored today. It is important to emphasize that the posterior stabilized designs do not provide coronal or sagittal stability. A constrained condylar polyethylene design
has an elevated and widened polyethylene eminence
which does provide AP, medial lateral, and rotational
stability although it cannot substitute for an absent collateral ligament.
> In reference to tibial component shape, both symmet-
ric and asymmetric designs continue to be used today
with excellent long-term outcomes.
1.10 The Evolution ofPolyethylene—The
Growth ofMid-Level Constraint
Over the years there have been several design adaptions
of the polyethylene liners in order to both improve the
stability of the joint and better replicate natural knee
> Newer mid-level constraint (MLC) bearings some-
what limit rotation and varus/valgus liftoff but have
less constraint than the constrained condylar knee
(CCK) insert.
The MLC compared to the PS design has an
increased height and width of the polyethylene insert
post, leading to a higher level of articulation with the
femoral box and increased congruity. It is often used to
correct valgus deformity resulting from the lateral bone
loss on the femur and deciency of the medial soft- tissue
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envelope. In this case, the contact between tibial emi-
1
nence and femoral box can act to reduce a hyperextension moment (Peters et al. 2001; Dubin and Westrich
2020).
(PFC) in 1985 (Scott and Thornhill 1994) (Depuy, Warsaw, IN), the Natural-Knee in 1985 (Hofmann et al.
1991) (Zimmer, Warsaw IN), and the Genesis I in 1988
(Smith and Nephew, Memphis, TN).
Since instability has proved to be the reason for
approximately 19% of revision TKA operations
1.11 The Evolution ofFixation inTKA
(Siddiqi etal. 2020), appropriate soft tissue balancing is
of high importance for a successful TKA.The tradi-
> The use of cemented implants remains the gold stan-
dard as cemented xation continues to provide durable long-term results in several large-scale registry
studies and randomized clinical trials (Papas et al.
2019; Nivbrant etal. 2020).
tional balancing techniques were mainly subjective and
relied on surgeon’s experience. Classically, there are two
techniques that are used in order to achieve the balance
of soft tissues in TKA: measured resection (MR) and
gap balancing (GB) (D’Lima etal. 2007). The rst one
uses xed osseous landmarks to plan bony cuts and
However, despite early failures with uncemented
designs (PCA), uncemented designs are increasingly
used and have demonstrated excellent mid-term survivorship in some more recent studies (Fricka etal. 2019).
The improvement in highly porous 3D printed titanium
coating and enhancements in peg and keel xation have
led to greater adoption. While the material properties
then performs soft tissue releases in order to achieve
symmetric exion and extension gaps (Hungerford
etal. 1982), whereas the second one uses the tension of
collateral ligament via soft-tissue releases as a guide to
balance exion and extension gaps and set component
rotation prior to osseous resection (Freeman et al.
1986).
have evolved signicantly over the years, the initial concepts and usage of uncemented total knee replacements
date back to over 40years.
1.12 Conclusion
In 1977, the cementless condylar knee design was
introduced. These prostheses were as follows:
5 The Kodama–Yamamoto
5 The Imperial College London Hospital (ICLH)
(Freeman etal. 1983)
5 The “Ring” prosthesis (Ring 1980)
5 One year later, the Low Contact Stress (LCS)
(Buechel and Pappas 1989) (Depuy, Warsaw, IN)
The evolution of TKA implant design and surgical
technique over the last two centuries is impressive.
Orthopedic surgeons have long recognized that the
denitive treatment of progressive, symptomatic arthritis is replacement of the articular surfaces with biocompatible, kinematically friendly prostheses. While initial
efforts focused more on optimizing the design features
of joint replacement implants, the importance of soft
In 1978 as well, Dr. David Hungerford, Robert
Kenna, and Dr. Kenneth Krackow designed the rst
porous-coated uncemented total knee replacement
(Hungerford etal. 1982). This initial design was groundbreaking in several aspects. Insertion of the implants
followed a press-t technique. This was the rst knee
design with a sintered porous-coated surface on the
backside of the femoral and tibial implant. The porouscoated anatomical (PCA) total knee, which was a posterior stabilized knee, was manufactured by Howmedica
(Rutherford, NJ). Ortholoc I followed in 1982 (Whiteside) (Whiteside 1989), The Tricon-M in 1983 (Smith
and Nephew, TN) (Laskin 1988), the Miller Galante
(MG-1) (Landon et al. 1986) in 1984, the Anatomic
Graduated Component (AGC) in 1984 (Ritter et al.
1992) (Biomet, Warsaw, IN), the Press-Fit Condylar
tissue balancing was recognized to be an equally important element of successful outcomes. As a result of the
complexity of knee joint kinematics, it is now known
that both accurate preoperative planning for bone
resection and ligament balancing are required for a successful postoperative result. The development of technology, improved instrumentation, and evolution of
biomaterials have improved TKA designs over the last
several decades. In addition, technology has been integrated into every aspect of TKA and has become an
important assistant not only in the preoperative but
also in the intraoperative execution of TKA.We owe a
great deal of gratitude to those innovative surgeons and
engineers who dedicated themselves to the constant
improvement of knee implant design and technique
and who continue to enable us to provide the reproduc-
The History ofTotal Knee Arthroplasty
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1
ible outcomes of improving pain and function in
patients with knee arthritis.
Take-Home Messages
5 Initial attempts for joint replacement started
during the nineteenth century.
5 First metallic implants designed were based on
the concept of hemiarthroplasty.
5 The concept of modern TKA was introduced in
the early 1970s with the Duocondylar prosthesis.
5 The total condylar prosthesis introduced the
idea of all three compartments replacement.
5 In the late 1970s, the Insall–Burstein prosthesis
was developed.
5 There is ongoing research regarding implants
design and joint alignment in order to improve
knee kinematics.
5 Cemented TKA is still the gold standard.
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plasty of the knee: a preliminary report. JBJS 45(8):1627–1642
Indications
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Contents
Chapter 2 Osteoarthritis – 17
Benjamin J. Levens, Eli Kamara, and Erik Hansen
Chapter 3 Osteoarthritis and Other Indications for Total Knee
Arthroplasty: An East African Perspective – 23
Seid Mohammed Yasin
Chapter 4 Inammatory Arthritis – 33
Zachary K. Christopher, Jaymeson R. Arthur,
and Mark J. Spangehl
15
II
Chapter 5 Osteonecrosis – 49
Hytham S. Salem, Brandon H. Naylor,
Kevin K. Mathew, and Michael A. Mont
Chapter 6 Post-Traumatic Arthritis – 57
Colin T. Penrose and Michael P. Bolognesi
Chapter 7 Post-Septic Arthritis – 67
Matan Ozery, Isaac Schultz, Tejbir S. Pannu,
Jesus M. Villa, and Carlos A. Higuera
Chapter 8 Inuence of Lifestyle and Risk Factors
on the Development of Knee Arthritis
and Outcomes Following Cemented Total Knee
Arthroplasty: A US Perspective – 75
Jonathan Dattilo and William Hamilton
Chapter 9 Lifestyle and Risk Factors for Knee Arthroplasty:
A South African Perspective – 89
Zia Maharaj and Jurek Rafal Tomasz Pietrzak
Chapter 10 The Microbiome of the Joint – 101
Samuel J. Clarkson, Karan Goswami, and Javad Parvizi
Osteoarthritis
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BenjaminJ.Levens, EliKamara, andErikHansen
Contents
2.1 Introduction – 18
2.2 Risk Factors – 18
2.3 Pathophysiology – 18
2.4 Diagnostic Features – 19
2.5 Treatment Options – 19
2.5.1 Nonoperative Management – 19
2.5.2 Surgical Intervention: Cemented Total Knee Arthroplasty – 21
17
2
2.6 Conclusion – 21
References – 21
© 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_2
18
B. J. Levens et al.
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2.1 Introduction
cules Smad3, β-catenin, and HIF-2α, and transcription
factor Runx2 are involved in OA development (Chen
According to the World Health Organization, musculo-
2
skeletal conditions are the leading cause of disability
worldwide (Musculoskeletal Conditions 2019). Among
etal. 2017). Although several different risk factors have
been indicated in the disease, the pathogenesis remains
fairly constant.
these conditions, osteoarthritis (OA) is one of the most
common, affecting more than 25% of the adult population (Chen etal. 2017). This number will continue to
2.3 Pathophysiology
rise as our population ages and the obesity rate
increases. As of 2012, the number of adults with OA in
the United States was 27 million. By 2030, that number
> On a cellular level, osteoarthritis is the failure to
regenerate damaged cartilage.
is projected to reach 67 million (Van Manen etal. 2012).
With the prevalence of OA increasing in the population, it is important to understand the pathophysiology,
diagnostic features, and treatment options for this disease.
Chondrocytes are the single cellular component of adult
hyaline cartilage and maintain the cartilage matrix under
normal conditions. Articular cartilage is composed of
type II collagen, which is named hyaline for its glass-like,
translucent appearance. Due to lack of vascularity in car-
> Osteoarthritis is the degeneration of joint cartilage
and underlying bone. One of the most common sites
of OA is the knee.
tilage, chondrocytes have limited supply of nutrients and
oxygen, which normally aid in cellular repair. Early in the
process of OA, chondrocytes attempt to repair damaged
areas by exhibiting a transient proliferative response
The burden caused by OA is a major reason for medical
visits and healthcare costs. Fifty percent of people who
are 50years and older report to have knee pain during
the course of a year (Blagojevic etal. 2010). A quarter
of them have severe or disabling knee pain, a number
that continues to rise. When reviewing the National
Health and Nutrition Examination Survey and Framingham Osteoarthritis Studies, Nguyen etal. found the
prevalence of knee pain and symptomatic OA roughly
doubled in women and tripled in men after adjusting for
age and body mass index over a 20-year period (Blagojevic etal. 2010; Nguyen etal. 2011).
increasing the synthesis of cartilage matrix, catabolic
cytokines, and matrix-degrading enzymes.
As mentioned previously, Runx2 is a key factor regulating the transcription of genes encoding matrix degradation enzymes in articular cartilage. Upregulation of
Runx2 causes increased production of degrading
enzymes such as metalloproteinases (MMPs), which
break down the extracellular matrix of cartilage and
cause apoptotic death of chondrocytes. The resulting
cartilage is unable to withstand mechanical stress, leading to a repetitive cycle of further breakdown.
Due to the lack of pain receptors in the cartilage,
these ndings typically do not present clinically until
later in the process. As cartilage debris and catabolic
2.2 Risk Factors
mediators break off from the cartilage and enter the
synovial cavity, macrophages from the synovial uid
Knee joint OA results in pain, swelling, stiffness, and
limited mobility. The cause of OA is multifactorial.
Several patient-specic risk factors have been associated
with the development of knee OA including the following:
5 Family history
5 Increased body mass index (BMI)
5 Prior knee injury
5 Female gender
5 Older age
take up these products and further amplify the inammatory response by releasing their own proinammatory markers. Although previously thought of as a
noninammatory disease, recent studies have shown
synovial inammation to be a cause of joint swelling
and pain (Chen etal. 2017; Bijlsma etal. 2011; Goldring
2000; Sellam and Berenbaum 2010).
As OA progresses on a molecular level, the resulting
process on a macroscopic scale leads to joint space narrowing, subchondral bone sclerosis, osteophyte formation, and cystic changes. These ndings can be visualized
Other factors are intensive physical activity including certain occupational activities such as kneeling and
squatting (Blagojevic etal. 2010). In addition, several
genetic factors have been implicated in the cause of OA.
Growth factors such as transforming growth factor-β
(TGF-β), Wnt3a, and Indian hedgehog, signaling mole-
on plain radiograph and are useful in the diagnosis of
Fig.2.1). More than 50% of patients older than
OA (.
65 have these radiographic changes, however, many of
these patients remain asymptomatic (Brown 2013). For
this reason, history and physical are crucial in proper
diagnosis and treatment of OA.
Osteoarthritis
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19
2.5 Treatment Options
After diagnosis, proper treatment is important.
> The Osteoarthritis Research Society International
(OARSI) recommends at least 6months of nonoperative treatment. If conservative, nonoperative management fails to improve symptoms after 6 months,
surgical intervention may be indicated (Van Manen
etal. 2012).
2.5.1 Nonoperative Management
There are many different nonoperative treatment modalities available for OA. The OARSI and American
Academy of Orthopaedic Surgeons (AAOS) each have
recommendations for treatment based on both clinical
research and expert opinion.
> Weight loss is strongly recommended by both the
AAOS and OARSI.
2
. Fig. 2.1 AP weight-bearing radiograph of a knee with signicant
arthritic changes
2.4 Diagnostic Features
> Among the symptoms of OA, pain is the most com-
mon initial symptom that patients report to their pri-
mary care physician. The pain is typically described
as intermittent, worse both during and after weight-
bearing activities. In addition to pain, patients also
complain of stiffness.
Stiffness associated with OA is most commonly felt in
the morning and resolves within a few minutes of getting up. Stiffness can help differentiate OA from Rheumatoid Arthritis (RA). Morning stiffness associated
with RA is dened as stiffness that resolves more than
30 minutes after getting up from sleep. Other common
symptoms are loss of movement and function, limiting
activities of daily living such as climbing stairs, prolonged walking, and doing household chores. The limitations caused by OA can diminish the quality of life
resulting in mood changes, anhedonia, and depression
(Bijlsma etal. 2011).
Generally, weight loss is recommended for patients with
symptomatic OA of the knee and a BMI ≥25 (Brown
2013). The Framingham Knee Osteoarthritis study
showed a greater than 50% reduction in symptoms
related to primary knee OA with a decrease in BMI of
two or more (Felson etal. 1987). The AAOS and OARSI
recommend weight loss by participating in self-managed
strengthening and low-impact aerobic exercises, as well
as engaging in physical activities focusing on muscle
strengthening and range of motion (Scuderi and Insall
1992; Zhang etal. 2008).
In addition to exercise, patients with symptomatic
OA also benet from referral to a physical therapist for
evaluation and instruction regarding appropriate exercises. These exercises should focus on pain reduction
and improvement of functional capacity. With the assistance of physical therapists, patients can also be evaluated for the need for walking aids such as a cane or
walker, which have been shown to reduce pain. In
patients with unilateral symptomatic OA, a cane or
crutch is recommended on the contralateral side. For
bilateral symptomatic OA, a framed or wheeled walker
is preferred (Zhang etal.
2008).
Usage of a valgus knee brace compared to neoprene
sleeve has been shown to improve Western Ontario
McMaster Universities Osteoarthritis Index (WOMAC)
scores, although there is only moderate strength of recommendation for this treatment by the OARSI.Similarly,
lateral wedged insoles for medial tibiofemoral compartment OA have been shown to reduce pain and improve
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