We have attempted to quantify the influence of clinical, radiological and prosthetic design factors upon flexion following knee replacement. Our study examined the outcome following 101 knee replacements performed in two prospective randomized trials using similar cruciate retaining implants. Multivariate analyses, after adjusting for age, sex, diagnosis and the type of prosthesis revealed that the only significant correlates for range of movement at 12-months were the difference in posterior condylar offset ratio (p<
0.001), tibial slope (p<
0.001) and preoperative range of movement (p=0.025). We found a moderate correlation between 12-month range of movement and posterior tibial slope (R=0.58) and the difference of post femoral condylar offset (that is, post-operative minus preoperative posterior condylar offset, R=0.65). Posterior condylar offset had the greatest impact upon final range of movement highlighting this as an important consideration for the operating surgeon at pre-operative templating when choosing both the design and size of the femoral component.
Surgical reconstruction of the injured Anterior Cruciate Ligament (ACL) is an effective solution to knee instability, but not all grafts incorporate well. The biological environment in the knee that controls graft integration is not well understood, and this study aims to fill that gap as the first step towards a translational approach to optimise outcomes. Over two stages, tissue samples and knee fluid samples were harvested from patients undergoing ACL reconstruction. These samples were cultured and stored to allow batch analysis for a variety of cytokines, growth factors and collagenases. Stage 1 (n=14) identified the presence of specific pro-inflammatory cytokines, growth factors and latent collagenase. Information gathered allowed a more targeted approach to be used in stage 2 (n=18). Stage 2 data from tissue cultures suggest that collagenase activity peaks later than 6 hours post-op. The relationships between collagenase activity and levels of TNF-alpha, IL-1beta and bFGF are of potential interest, and the profiles of patients will be compared with longer term follow-up data to determine any effects on outcomes. Further detailed assessment of the biology of ACL graft incorporation is required, but these preliminary data have clarified some of the details worthy of further study.
The Kinemax Plus knee replacement has a reported 10 year survival of around 96%. However we found the survival rate of this implant in our cohort to be 75% at 9 years. No abnormalities were found for clinical and radiological parameters. At reoperation the most striking feature was that of significant ultra-high molecular weight polyethylene (UHMWPE) failure. Oxidative and structural analysis of the polyethylene components was therefore undertaken. Ten Kinemax Plus tibial inserts were analysed; one was a shelf-aged unused implant, the others were explants. An FTIR analysis of the data showed that oxidation is present in all samples. The degree of oxidation however varied with depth and location. Except for a sharp oxidative peak approximately half way into the sample, the shelf aged samples had a fairly constant level of oxidation. The retrieved implants had an overall higher level of oxidation in both bearing and non-bearing regions. The latter had less of a variation in oxidation which implies that in vivo loading exaggerates the degree of oxidation. In the non-articulating regions oxidation of the explants was found to peak often at the region of about 40% from the bottom surface in all retrieved samples. By contrast, most articulating region had two oxidative peaks; one occurring at approximately 1–1.5mm from the surface, which is consistent with findings on subsurface oxidation, and another occurring about 2–3mm from the bottom surface. SEM imaging provided evidence for the presence of fusion defects by indicating grain boundaries through-out the explants. This indicates a compromised material which is more susceptible to damage. Fatigue loading of the implant has also been seen to produce a subsurface stress maximum at approximately 1 to 2mm below the articulating surface. It is thought that maximum contact stresses within this region cause Type 1 and Type 2 defects to open or become more pronounced. This in turn will increase the local concentration of oxygenating material as it will be present in these defects and voids where surface areas are greater for oxidative reaction. We therefore hypothesise that these fusion defects are the cause for the early failure of the Kinemax implants.
We aim to explain the significant difference in survivor-ship found between two cohorts of patients who underwent different total knee replacements. The first cohort included 70 patients who underwent Kinemax Plus total knee replacement, the second cohort included 58 patients who underwent PFC Total Knee replacement. All patients were under the care of one Consultant Orthopaedic Surgeon. Interestingly, the Kinemax Plus cohort was found to have a higher rate of revision as compared to the PFC cohort. A detailed comparison was then carried out between the two groups to identify any obvious cause for the disparity. The two cohorts were found to be well matched with respect to age, sex, ASA grade, underlying pathology and operative technique. Median follow up being 6 years and 5 years for the Kinemax and PFC groups respectively. There were 11 failed prostheses in the kinemax cohort, 7 undergoing revision with the remaining 4 patients offered revision but unwilling have surgery. Wear of the polyethylene tibial insert was the most obvious finding at revision, present in six out of the 7 revisions. 97% of the Kinemax Plus Prostheses were intact at 5 years but by 8 years only 87% were intact. There were no revisions performed in the PFC cohort. Post operative x-ray analysis was undertaken to rule out prosthesis misalignment as a cause for the increased failure rate. The coronal alignment of the prostheses (CAK) was calculated and all post operative x-rays were within the normal limits of 4–10 degrees. Analysis of the explanted Kinemax Plus polyethylene liners was undertaken. In six cases, the polyethylene bearing surfaces displayed severe surface and subsurface delamination at both medial and lateral sides. This suggests massive fatigue and fatigue wear. Only one inplant showed localised delamination. The surface characterisation suggests the hypothesis of weak UHMWPE particle interface strength.
We describe a cohort of patients with a high rate of mid-term failure following Kinemax Plus total knee replacement inserted between 1998 and 2001. This implant has been recorded as having a survival rate of 96% at ten years. However, in our series the survival rate was 75% at nine years. This was also significantly lower than that of subsequent consecutive series of PFC Sigma knee replacements performed by the same surgeon. No differences were found in the clinical and radiological parameters between the two groups. At revision the most striking finding was polyethylene wear. An independent analysis of the polyethylene components was therefore undertaken. Scanning electron microscopy revealed type 2 fusion defects in the ultra-high molecular weight polyethylene (UHMWPE), which indicated incomplete boundary fusion. Other abnormalities consistent with weak UHMWPE particle interface strength were present in both the explanted inserts and in unused inserts from the same period. We consider that these type 2 fusion defects are the cause of the early failure of the Kinemax implants. This may represent a manufacturing defect resulting in a form of programmed polyethylene failure.
We report the results of a prospective randomised controlled clinical trial assessing the radiosterophotogrametric analysis (RSA), clinical and radiological performance of a metal backed and an all-polyethylene tibial cruciate retaining, condylar design, PFC-TKA up to twenty four months. 65 patients were recruited, of which 41 patients were randomised. There were 20 metal backed and 21 all-polyethylene. None were lost to follow-up. There were no significant inter-group demographic differences. We found a significant increase in SF-12 and Oxford knee scores after surgery in both groups. No significant difference was found between the groups in the RSA, SF-12, Oxford Knee score, radiological alignment and range of movement at 6, 12 or 24 months. At 2 years one metal backed implant showed translational migration >
1mm. No all polyethylene implant migrated >
1mm. Further analysis identified possible progressive subsidence of the metal backed implants compared to all-polyethylene implants, although the magnitude of this difference was very small. We conclude that in the uncomplicated primary total knee arthroplasty, all polyethylene PFC-_ tibial prostheses had equivalent performance to the metal backed counterpart, using RSA as the primary assessment instrument at 24 months. We found no differences between the two designs as assessed by the secondary instruments: SF-12, Oxford knee score, alignment and range of movement at 24 months. Should half of all primary total knee replacements performed in the UK receive an all-polyethylene tibial implant, the estimated annual cost saving would be 21 million pounds per annum.
The aim of this longitudinal study is to compare the clinical outcomes of endoscopic ACL reconstruction with either a 4-strand HT or PT autograft over a 5-year period. 90 patients with isolated ACL rupture received PT autograft and 90 received HT autograft were studied annually for 5 years. Assessment included the IKDC Knee Ligament Evaluation, KT1000, Lysholm Knee Score, thigh atrophy, kneeling pain, hamstring pain and radiographs. The median Lysholm Knee Score was 96 for the PT group and 95 for the HT group. No significant difference was found for subjective knee function, overall IKDC assessment, Xray findings, manual ligament KT1000 instrumented testing, graft rupture or contralateral ACL rupture. There was an increasing incidence of fixed flex-ion deformity seen in the PT group. There was no difference in the requirement for subsequent surgery. The incidence of kneeling pain at 5 years was significantly higher in the PT group. Endoscopic reconstruction of the ACL utilizing either autograft can restore knee stability and is menisco protective despite a high level of sporting activity. We did find a worrying trend towards an increasing incidence of fixed flexion deformity with time in the patellar tendon group. Kneeling pain also remains a persistent problem in this subgroup.