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The total condylar III knee prosthesis in elderly patients
The Total Condylar 11I Knee Prosthesis in Elderly Patients
C h r i s t o p h e r H. K a v o l u s , M D , * P h i l i p M . Faris, MD,-IM e r r i l l A. Ritter, MD,-i- a n d E. M i c h a e l K e a t i n g , MD-i"
Abstract: Sixteen knee arthroplasties using a total condylar III prosthesis were
performed in 14 patients with an average follow-up period of 4.5 years and a minimum follow-up period of 3 years. Eleven of the sixteen knee arthroplasties were revision prostheses. The average age was 71 years, with all but three patients being 69 years of age or older. In this age group, fifteen of sixteen implants had a good to excellent IIospital for Special Surgery (HSS) knee score at the most recent follow-up evaluation. One patient had a fair score, the result of a remote postoperative proximal tibial fracture, and requires a long leg brace for ambulation. Key words: Constrained prosthesis, elderly, soft tissue incompetence, revision arthroplasty, medial collateral ligament laxity.
Total knee arthroplasty has evolved away frbm tile hinged-type and constrained prostheses, which are associated with unacceptably high infection rates and mechanical loosening(I, 3, 4, 5, 7). There are times, however, w h e n a semiconstrained prosthesis will not provide acceptable stability. The two most notable occasions are a revision arthroplasty secondary to tissue incompetence and a primary arthroplasty performed in an individual with an extreme valgus deformity and medial collateral ligament laxity. In these instances increased stability is required for the implant to provide a stable functional arthroplasty. Two recent articles evaluated 70 Total Condylar III knee protheses and revealed good results with primary arthroplasty and less encouraging results w h e n this prosthesis was used for revision arthroplasty (2, 6). We have reviewed our patient population to see whether our experience with the Total
Condylar III knee prosthesis supported these findings or if this prosthesis would be more successful in revision arthroplasty w h e n used in an older population.
Materials and Methods Sixteen Total Condylar III protheses (Zimmer, Warsaw, IN) were implanted in 14 patients between 1981 and 1985 by the senior author (M.A.R). The average age was 71 years ( 5 8 - 8 4 ) . All but three patients were 69 years old or older. There were nine w o m e n and five men in this study. Bilateral primary total knee arthroplasties were performed in two of the patients. Eleven revision arthroplasties were performed, ten for aseptic 16osening and one because of an infection. Five primary arthroplasties were done, three to treat osteoarthritis and two for rheumatoid arthritis. One patient with the diagnosis of osteoai-thritis and one with the diagnosis of rheumatoid arthritis had bilateral total knee replacements. In all the primary
* From the Center for tlip and Knee Surgery, Mooresville, htdiana, and ~the Department of Orthopaedic Surgery, Louisiana State Unirersity, Medical Center hz Shreveport, LouisCana.
Reprint requests: Merrill A. Ritter, MD, 1199 Hadley Road, Mooresville, IN 46158. 39
40
The Journal of Arthroplasty Vol. 6 No. 1 March 1991
arthroplasties, severe valgus deformities with medial collateral ligament incompetence were present. The patients were observed for a minimum of 3 years postoperatively (average 5 years for primary surgery, 4.2 years for revision). All knees were scored using the Hospital for Special Surgery (HSS) kneescoring system. Radiographs were evaluated for loosening, radiolucency, and progressive radiolucency.
Results The revision knee arthroplasty HSS scores were five knees with an excellent score, five with a good score and one with a fair score (average 84, range
6 9 - 9 6 ) . All five primary knee arthroplasties hacl excellent scores (average 93.4, range 8 8 - 9 7 ) . We had no poor results and no revisions. Pain was evaluated on a scale of 0 to 30 using the HSS knee-scoring system. Twelve knees scored 30, no pain at any time; two knees scored 25, occasional and mild pain with activity; and two knees scored 20, occasional mild pain with activity and rest. Range of motion data reveal that all knees obtained full extension with no extension lag. One knee had 80 ~ of flexion, one knee had 85 ~ of flexion, and two knees had 95 ~ of flexion. The remaining 12 knees achieved at least 100 ~ of flexion (average 112 ~ range 8 0 - 1 2 5 ~ (Table 1). Five of the patients with revision knee arthroplasties a n d all five with primary arthroplasties achieved unlimited walking and standing ability.
Fig. 1. (A) Total knee anhroplasty revision 2 months postoperatively. (B) Same patient 7 years postoperatively with subsidence and drift of tibial prosthesis.
Total Condylar I11 Knee Prosthesis in Elderly Patients
Table 1. Hospital for Special Surgery Knee Score No. Knees Results Excellent (100-85) Good (84-70) Fair (69-60) Poor (<60) Pain (0-30) 30 25 20 Range of motion 0-80 0-85 0-95 0->100
I0 5 l 0 12 2 2-1 l 2 12
9
Kavolus et al.
41
cencies. One patient also demonstrated a proximal tibia fracture radiographically (HSS score 69). Three radiolucencies were found in the five patients with primary arthroplasties (60%). Two were nonprogressive radiolucencies about the femoral stem and one was a progressive lucency about the tibial component. The anatomic alignment ranged from 4 ~ of varus to 18 ~ of valgus (average 5.6 ~ valgus). Three of the five progressive radiolucencies occurred in arthroplasties having an acceptable anatomic range of 5 to 7 ~ of valgus.
Five individuals with revision prostheses were able to walk one to five blocks and one individual just one block. This one patient had sustained a proximal tibial fracture, which occurred 2 years after surgery requiring a long leg brace and crutches for ambulation. Only one other person required a cane for ambulatory assistance.
Radiographic Correlations Of 16 total knee arthroplasties, eight (50%) had evidence of radiolucency in at least one zone. Two individuals demonstrated radiolucency in both the tibia and patella so that there were 10 total components with radiolucency out of a possible 46. In 2 of the 16 implants, patellar resurfacing was not done (HSS score 79 each). Tibial c o m p o n e n t radiolucencies, all of which were progressive, were found in four knees (Fig. 1). Four femoral component radiolucencies were found, of which one was progressive. Two patellar radiolucencies were progressive and were found in combination with progressive tibial radiolucencies. (Table 2). In performing radiographic interpretations, we attempted to err o n the side of progressive radiolu-
0
T a b l e 2. N u m b e r o f R a d i o l u c e n c i e s
Revision Tibia Femur Patella Primary Tibia Femur Patella
r
Initial
Recent
Progressive
2 2 0
3 2 2
3 1 2
0 2 0
-1 2 0
1 0 0
Fig. 2. Proximal tibial fracture in a long leg b r a c e w i t h progressive tibial radiolucency, 3 years after o p e r a t i v e revision of a GUEPAR prosthesis u s i n g t h e total c o n d y l a r III k n e e prosthesis.
42
The Journal of Arthroplasty Vol. 6 No. 1 March 1991
Complications Two patients suffered myocardial infarctions at 2 months and 5 months postoperatively. One of these patients rated a " g o o d " score; the other patient had additionally a proximal tibial fracture (Fig. 2), required a long leg brace, and had a "fair" score. One individual developed a peroneal nerve palsy after revision arthroplasty. This complication resolved, and the patient's most recent functional score was excellent. Two patellar dissociations occurred. Both patients were treated conservatively, had excellent knee scores, and were asymptomatic.
Discussion Previous studies have demonstrated good success in using Total Condylar III prostheses in primary joint arthroplasty of the knee in patients with a severe valgus deformity and medial collateral ligament incompetence (2, 6). Reports have been less favorable regarding this prosthesis w h e n employed for revision arthroplasty. Five of fourteen revision arthroplasties reviewed by Donaldson and associates (2) failed and three of seventeen revision arthroplasties evaluated by Kraay and associates (6) also failed. We
have performed eleven revision arthroplasties using this procedure with no revisions and only one fair result. In our study, the average age of the patients was 71 years, 4 years older than Kraay or Donaldson's average. Less prosthetic d e m a n d in these older patients m a y have positively affected our results. The two patellar dissociations that occurred (Fig. 3) may be related to the small radius of curvature of the patellar groove on the femoral c o m p o n e n t or to compromised host bone stock as often seen in revision arthroplasty. Also, the association between the two progressive tibial and patellar radiolucencies suggests that tibial loosening alters patellar tracking and predisposes the patellar c o m p o n e n t to early loosening. Our database is too small and our followup evaluation too short to allow any significant statistical interpretation of this concern. Eight of our sixteen arthroplasties had a radiolucency (50%) and five demonstrated progressive lucencies about the tibial and femoral components. Although these findings may portend problems with prosthetic loosening, clinical function remains excellent. Only one of four lucencies about the femoral stem was noted to be progressive. Recent evidence suggests that a cement mantle around long intramedullary stems may be associated with an increased incidence of radiolucency and certainly increases the difficulty of revision (8). Consequently we no longer
Fig. 3. Two patellar dislocations. (A) 2 postoperative months. (B) 6 postoperanve months: note loss of curvature and deformation of wire (arrow) suggesting fatigue. (Figure conthntes)
Fig. 3. (C) 1 postoperative year, now with failure. (D) 3 postoperative years with final remodeling.
Total Condylar III Knee Prosthesis in Elderly Patients
place cement around these stems unless it is necessary for stability of the bone/prosthesis construct. This report, with an average follow-up period of 4.5 years, supports the continued use of the Total Condylor III prosthesis in those difficult arthroplasty revisions in which a hinged arthroplasty, fusion, or a m p u t a t i o n might otherwise be required. It is also indicated for primary use in the older, less active population in w h o m ligament instability would m a k e semiconstrained designs difficult to perform or unacceptably unstable. A third and m o r e unusual circumstance for use of this prosthesis is in the case of inadvertent transection of the medial collateral liga m e n t during standard total knee arthroplasty.
2.
3. 4.
5.
6.
References
7.
1. Barger WL, Cracchiolo A, Amstutz HC: Results with the constrained total knee prosthesis in treating se-
8.
9
Kavolus et al. 43
verely disabled patients and patients with failed total knee replacements. J Bone Joint Surg 62A(4):504-512, 1980 Donaldson WF, Sculco TP, Insall JN, Ranawat CS: Total Condylar III knee prosthesis: Long-term follow-up study. Clin Orthop 226:21-28, 1988 Hui FC, Fitzgerald RH: Hinged total knee arthroplasty. Orthop Trans 2:195, 1978 Jones EC, Insall JN, Inglis AE, Ranawat CS: GUEPAR knee arthroplasty results and late complications. Clin Orthop 140:145-152, 1979 Karpinski MRK, Grimer RJ: Hinged knee replacement in revision arthroplasty. Clin Orthop 220:185-191, 1987 Kraay M, Goldberg VM, Figgie MP, Sobel M, Fisher DA: Technical factors influencing the results of total condylar III knee arthroplasty. Am J Knee Surg 1(2):125-133, April 1988 Murray DG, Wilde AH, Wemer F, Foster D: Herbert total knee prosthesis. Combined laboratory and clinical assessment. J Bone Joint Surg 59A:221-240, 1977 Urs W, Binazzi R, Insall JN, et al: Presented AAOS, Atlanta, 1988
C h r i s t o p h e r H. K a v o l u s , M D , * P h i l i p M . Faris, MD,-IM e r r i l l A. Ritter, MD,-i- a n d E. M i c h a e l K e a t i n g , MD-i"
Abstract: Sixteen knee arthroplasties using a total condylar III prosthesis were
performed in 14 patients with an average follow-up period of 4.5 years and a minimum follow-up period of 3 years. Eleven of the sixteen knee arthroplasties were revision prostheses. The average age was 71 years, with all but three patients being 69 years of age or older. In this age group, fifteen of sixteen implants had a good to excellent IIospital for Special Surgery (HSS) knee score at the most recent follow-up evaluation. One patient had a fair score, the result of a remote postoperative proximal tibial fracture, and requires a long leg brace for ambulation. Key words: Constrained prosthesis, elderly, soft tissue incompetence, revision arthroplasty, medial collateral ligament laxity.
Total knee arthroplasty has evolved away frbm tile hinged-type and constrained prostheses, which are associated with unacceptably high infection rates and mechanical loosening(I, 3, 4, 5, 7). There are times, however, w h e n a semiconstrained prosthesis will not provide acceptable stability. The two most notable occasions are a revision arthroplasty secondary to tissue incompetence and a primary arthroplasty performed in an individual with an extreme valgus deformity and medial collateral ligament laxity. In these instances increased stability is required for the implant to provide a stable functional arthroplasty. Two recent articles evaluated 70 Total Condylar III knee protheses and revealed good results with primary arthroplasty and less encouraging results w h e n this prosthesis was used for revision arthroplasty (2, 6). We have reviewed our patient population to see whether our experience with the Total
Condylar III knee prosthesis supported these findings or if this prosthesis would be more successful in revision arthroplasty w h e n used in an older population.
Materials and Methods Sixteen Total Condylar III protheses (Zimmer, Warsaw, IN) were implanted in 14 patients between 1981 and 1985 by the senior author (M.A.R). The average age was 71 years ( 5 8 - 8 4 ) . All but three patients were 69 years old or older. There were nine w o m e n and five men in this study. Bilateral primary total knee arthroplasties were performed in two of the patients. Eleven revision arthroplasties were performed, ten for aseptic 16osening and one because of an infection. Five primary arthroplasties were done, three to treat osteoarthritis and two for rheumatoid arthritis. One patient with the diagnosis of osteoai-thritis and one with the diagnosis of rheumatoid arthritis had bilateral total knee replacements. In all the primary
* From the Center for tlip and Knee Surgery, Mooresville, htdiana, and ~the Department of Orthopaedic Surgery, Louisiana State Unirersity, Medical Center hz Shreveport, LouisCana.
Reprint requests: Merrill A. Ritter, MD, 1199 Hadley Road, Mooresville, IN 46158. 39
40
The Journal of Arthroplasty Vol. 6 No. 1 March 1991
arthroplasties, severe valgus deformities with medial collateral ligament incompetence were present. The patients were observed for a minimum of 3 years postoperatively (average 5 years for primary surgery, 4.2 years for revision). All knees were scored using the Hospital for Special Surgery (HSS) kneescoring system. Radiographs were evaluated for loosening, radiolucency, and progressive radiolucency.
Results The revision knee arthroplasty HSS scores were five knees with an excellent score, five with a good score and one with a fair score (average 84, range
6 9 - 9 6 ) . All five primary knee arthroplasties hacl excellent scores (average 93.4, range 8 8 - 9 7 ) . We had no poor results and no revisions. Pain was evaluated on a scale of 0 to 30 using the HSS knee-scoring system. Twelve knees scored 30, no pain at any time; two knees scored 25, occasional and mild pain with activity; and two knees scored 20, occasional mild pain with activity and rest. Range of motion data reveal that all knees obtained full extension with no extension lag. One knee had 80 ~ of flexion, one knee had 85 ~ of flexion, and two knees had 95 ~ of flexion. The remaining 12 knees achieved at least 100 ~ of flexion (average 112 ~ range 8 0 - 1 2 5 ~ (Table 1). Five of the patients with revision knee arthroplasties a n d all five with primary arthroplasties achieved unlimited walking and standing ability.
Fig. 1. (A) Total knee anhroplasty revision 2 months postoperatively. (B) Same patient 7 years postoperatively with subsidence and drift of tibial prosthesis.
Total Condylar I11 Knee Prosthesis in Elderly Patients
Table 1. Hospital for Special Surgery Knee Score No. Knees Results Excellent (100-85) Good (84-70) Fair (69-60) Poor (<60) Pain (0-30) 30 25 20 Range of motion 0-80 0-85 0-95 0->100
I0 5 l 0 12 2 2-1 l 2 12
9
Kavolus et al.
41
cencies. One patient also demonstrated a proximal tibia fracture radiographically (HSS score 69). Three radiolucencies were found in the five patients with primary arthroplasties (60%). Two were nonprogressive radiolucencies about the femoral stem and one was a progressive lucency about the tibial component. The anatomic alignment ranged from 4 ~ of varus to 18 ~ of valgus (average 5.6 ~ valgus). Three of the five progressive radiolucencies occurred in arthroplasties having an acceptable anatomic range of 5 to 7 ~ of valgus.
Five individuals with revision prostheses were able to walk one to five blocks and one individual just one block. This one patient had sustained a proximal tibial fracture, which occurred 2 years after surgery requiring a long leg brace and crutches for ambulation. Only one other person required a cane for ambulatory assistance.
Radiographic Correlations Of 16 total knee arthroplasties, eight (50%) had evidence of radiolucency in at least one zone. Two individuals demonstrated radiolucency in both the tibia and patella so that there were 10 total components with radiolucency out of a possible 46. In 2 of the 16 implants, patellar resurfacing was not done (HSS score 79 each). Tibial c o m p o n e n t radiolucencies, all of which were progressive, were found in four knees (Fig. 1). Four femoral component radiolucencies were found, of which one was progressive. Two patellar radiolucencies were progressive and were found in combination with progressive tibial radiolucencies. (Table 2). In performing radiographic interpretations, we attempted to err o n the side of progressive radiolu-
0
T a b l e 2. N u m b e r o f R a d i o l u c e n c i e s
Revision Tibia Femur Patella Primary Tibia Femur Patella
r
Initial
Recent
Progressive
2 2 0
3 2 2
3 1 2
0 2 0
-1 2 0
1 0 0
Fig. 2. Proximal tibial fracture in a long leg b r a c e w i t h progressive tibial radiolucency, 3 years after o p e r a t i v e revision of a GUEPAR prosthesis u s i n g t h e total c o n d y l a r III k n e e prosthesis.
42
The Journal of Arthroplasty Vol. 6 No. 1 March 1991
Complications Two patients suffered myocardial infarctions at 2 months and 5 months postoperatively. One of these patients rated a " g o o d " score; the other patient had additionally a proximal tibial fracture (Fig. 2), required a long leg brace, and had a "fair" score. One individual developed a peroneal nerve palsy after revision arthroplasty. This complication resolved, and the patient's most recent functional score was excellent. Two patellar dissociations occurred. Both patients were treated conservatively, had excellent knee scores, and were asymptomatic.
Discussion Previous studies have demonstrated good success in using Total Condylar III prostheses in primary joint arthroplasty of the knee in patients with a severe valgus deformity and medial collateral ligament incompetence (2, 6). Reports have been less favorable regarding this prosthesis w h e n employed for revision arthroplasty. Five of fourteen revision arthroplasties reviewed by Donaldson and associates (2) failed and three of seventeen revision arthroplasties evaluated by Kraay and associates (6) also failed. We
have performed eleven revision arthroplasties using this procedure with no revisions and only one fair result. In our study, the average age of the patients was 71 years, 4 years older than Kraay or Donaldson's average. Less prosthetic d e m a n d in these older patients m a y have positively affected our results. The two patellar dissociations that occurred (Fig. 3) may be related to the small radius of curvature of the patellar groove on the femoral c o m p o n e n t or to compromised host bone stock as often seen in revision arthroplasty. Also, the association between the two progressive tibial and patellar radiolucencies suggests that tibial loosening alters patellar tracking and predisposes the patellar c o m p o n e n t to early loosening. Our database is too small and our followup evaluation too short to allow any significant statistical interpretation of this concern. Eight of our sixteen arthroplasties had a radiolucency (50%) and five demonstrated progressive lucencies about the tibial and femoral components. Although these findings may portend problems with prosthetic loosening, clinical function remains excellent. Only one of four lucencies about the femoral stem was noted to be progressive. Recent evidence suggests that a cement mantle around long intramedullary stems may be associated with an increased incidence of radiolucency and certainly increases the difficulty of revision (8). Consequently we no longer
Fig. 3. Two patellar dislocations. (A) 2 postoperative months. (B) 6 postoperanve months: note loss of curvature and deformation of wire (arrow) suggesting fatigue. (Figure conthntes)
Fig. 3. (C) 1 postoperative year, now with failure. (D) 3 postoperative years with final remodeling.
Total Condylar III Knee Prosthesis in Elderly Patients
place cement around these stems unless it is necessary for stability of the bone/prosthesis construct. This report, with an average follow-up period of 4.5 years, supports the continued use of the Total Condylor III prosthesis in those difficult arthroplasty revisions in which a hinged arthroplasty, fusion, or a m p u t a t i o n might otherwise be required. It is also indicated for primary use in the older, less active population in w h o m ligament instability would m a k e semiconstrained designs difficult to perform or unacceptably unstable. A third and m o r e unusual circumstance for use of this prosthesis is in the case of inadvertent transection of the medial collateral liga m e n t during standard total knee arthroplasty.
2.
3. 4.
5.
6.
References
7.
1. Barger WL, Cracchiolo A, Amstutz HC: Results with the constrained total knee prosthesis in treating se-
8.
9
Kavolus et al. 43
verely disabled patients and patients with failed total knee replacements. J Bone Joint Surg 62A(4):504-512, 1980 Donaldson WF, Sculco TP, Insall JN, Ranawat CS: Total Condylar III knee prosthesis: Long-term follow-up study. Clin Orthop 226:21-28, 1988 Hui FC, Fitzgerald RH: Hinged total knee arthroplasty. Orthop Trans 2:195, 1978 Jones EC, Insall JN, Inglis AE, Ranawat CS: GUEPAR knee arthroplasty results and late complications. Clin Orthop 140:145-152, 1979 Karpinski MRK, Grimer RJ: Hinged knee replacement in revision arthroplasty. Clin Orthop 220:185-191, 1987 Kraay M, Goldberg VM, Figgie MP, Sobel M, Fisher DA: Technical factors influencing the results of total condylar III knee arthroplasty. Am J Knee Surg 1(2):125-133, April 1988 Murray DG, Wilde AH, Wemer F, Foster D: Herbert total knee prosthesis. Combined laboratory and clinical assessment. J Bone Joint Surg 59A:221-240, 1977 Urs W, Binazzi R, Insall JN, et al: Presented AAOS, Atlanta, 1988