Table Of ContentTheofi los Karachalios
Editor
Total Knee Arthroplasty
Long Term Outcomes
123
Total Knee Arthroplasty
Theofi los Karachalios
Editor
Total Knee Arthroplasty
Long Term Outcomes
Editor
Theofi los Karachalios
Orthopaedic Department
University of Thessalia
Larissa
Greece
ISBN 978-1-4471-6659-7 ISBN 978-1-4471-6660-3 (eBook)
DOI 10.1007/978-1-4471-6660-3
Library of Congress Control Number: 2015941517
Springer London Heidelberg New York Dordrecht
© Springer-Verlag London 2015
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specifi c statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.
Printed on acid-free paper
Springer-Verlag London Ltd. is part of Springer Science+Business Media (www.springer.com)
Pref ace
Up to the 1960s and early 1970s, it was common to see crippled women and
men, with hip and knee joint deformities and serious restriction of movement,
tottering very short distances using various walking aids. Patients often
described how agonisingly painful their arthritic joints were. In November
1962, just over 50 years ago, the pioneer of hip reconstruction surgery, Sir
John Charnley, made a modern breakthrough. Thanks to basic scientists,
engineers, the industry and dedicated orthopaedic surgeons who have invested
their scientifi c and professional lives to adult reconstructive surgery, we can
now provide arthritic patients with painless joint movement and restoration of
function.
The origins of total knee arthroplasty (TKA) can be traced back to 1889 in
Berlin, where Themistocles Gluck gave a series of lectures describing a sys-
tem of joint replacement using a unit made of ivory, using pumice and plaster
of Paris. In the 1950s, the fi rst surface replacement of the tibia was developed
by McKeever. During the next decade, designers focused their efforts on con-
strained or hinged prostheses or on condylar replacement. Pioneering implant
designs were problematic, mainly due to a high percentage of component
loosening, breakages of the components and infection. Due to the complexity
of knee joint biomechanics and kinematics, the clinical use of effective TKA
designs was delayed by at least 15 years when compared with total hip arthro-
plasty (THA). The design phase of the 1970s and 1980s resulted in two dif-
ferent approaches, the anatomical and the functional, and this was the real
advent of satisfactory clinical use of TKAs.
T otal joint arthroplasty developed into one of the most important fi elds of
surgery in the twentieth century [1]. However, the road to success for TKA
has been neither easy nor without obstacles. Problems of surgical technique
and soft tissue balancing arose; low-quality implants were used; patterns of
failure were recognised; patellofemoral joint issues produced a high inci-
dence of failure; surgeons have had to learn from devastating clinical failures,
and patients have often been “fashion victims” in both TKA and THA [2].
D uring the early decades when the fi eld arthroplasty was developing, sur-
geons were infl uenced by expert opinions and by studies undertaken by the
designers of materials, which were sometimes biased. Industry-infl uenced
data was neither fi ltered nor thoroughly assessed. We were led to believe that
the implant is to blame for failures, and due to the lack of strong evidence to
support the principles of our surgical techniques, we familiarised ourselves
with both good and bad arthroplasty stratagems. Fortunately, we now have
v
vi Preface
reliable educational and training programmes, we critically review
high- quality literature and have evidence-based studies (Level I and II RCTs,
meta-analysis and national registry data), and continental regulatory bodies
inform and scrutinise industrial proposals. We also carefully record the com-
plications that arise in our procedures and take preventive measures. It is now
accepted that the long-term survival of a TKA is a multifactorial issue, since,
other than the implant, factors related to diagnosis, the patient, the surgeon
and surgical technique are also important. Added to these issues, there is the
matter of fi nance. Health providers justifi ably question the cost-effectiveness
of arthroplasty procedures and especially the need for the introduction of
newer, more expensive techniques and implants, which makes the need for
systematic and credible research all the more important.
The knee joint functions as a type of biological transmission whose pur-
pose is to accept and transfer a range of loads between and among the femur,
patella, tibia and fi bula without causing structural or metabolic damage. The
purpose of a joint arthroplasty is to maximise the envelope of function for a
given joint as safely as possible. It is a matter of optimised load transfer, the
kinematics of the artifi cial joint, design issues and soft tissue metabolic and
functional status. In the late 1990s, it was suggested that knees which had had
joint arthroplasty surgery do not replicate the functional status of a healthy,
uninjured adult joint. It has been also observed that patients with TKAs walk
differently compared to normal controls. They show slower walking speed,
shorter stride length, less time spent in the stance phase and stiff-legged gait.
Many subjects also demonstrate an anterior sliding of the femur on the tibia,
a phenomenon named paradoxical motion which has signifi cant implications
for the functional results of TKA. In the light of these observations, compli-
cations like irregular kinematics, abnormal patellar tracking, polyethylene
wear and poor range of motion can be explained. Functional recovery in TKA
is slow; a signifi cant number of patients are not happy with the functional
outcome of the procedure and feel that their surgery was not successful in
enabling them to resume their regular physical activities or participate in age-
appropriate recreational and sports activities.
F or current practice and the future development of TKA, we need to be
able to reply to the following questions: What is the optimal design and fi xa-
tion of the implants we use for knee arthroplasty reconstruction? What are the
gold standards? Can we do better? In an attempt to throw light on these ques-
tions, the present authors critically evaluate data from long-term clinical stud-
ies and assess various factors which may infl uence outcome. It is our opinion
that even though much effort has been put into research, both by individual
research centres and the implant industry, this has not always translated into
the improvement of clinical outcome, and cost-effectiveness has not often
been taken into account. It is also apparent that theoretical and laboratory
studies do not always hold up in the cold morning light of long-term clinical
studies and that there are few quality Level I and II clinical outcome studies.
I n this book we focus on the long-term outcome of TKA, and we hope it
will be useful both for the novice who seeks a quick introduction to this spe-
cifi c topic and for more experienced surgeons who seek an in-depth critical
review of current practices.
Preface vii
References
1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replace-
ment. Lancet. 2007;370(0597):1508–19.
2. Muirhead-Allwood SK. Lessons of a hip failure. BMJ. 1998;316(7132):644.
3 . Blaha JD. The rationale for a total knee implant that confers anteroposterior stability
throughout range of motion. J Arthroplasty. 2004;19:22–6.
Larissa , Hellenic Republic Theofi los Karachalios
Contents
1 A Brief History of Total Knee Arthroplasty . . . . . . . . . . . . . . . 1
Konstantinos Makridis and Theofi los Karachalios
2 Kinematics of the Natural and Replaced Knee. . . . . . . . . . . . . 7
Lisa G. Coles, Sabina Gheduzzi, Anthony W. Miles,
and Harinderjit S. Gill
3 Long Term Survival of Total Knee Arthroplasty.
Lessons Learned from the Clinical Outcome
of Old Designs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Konstantinos Makridis and Theofi los Karachalios
4 Long Term Survival of Total Knee Arthroplasty.
Lessons Learn from the Clinical Outcome
of Old Designs. Second Generation of Implants
and the Total Condylar TKA . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Konstantinos Makridis and Theofi los Karachalios
5 Total Knee Arthroplasty. Evaluating Outcomes. . . . . . . . . . . . 39
Elias Palaiochorlidis and Theofi los Karachalios
6 The Long Term Outcome of Total Knee Arthroplasty.
The Effect of Age and Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . 49
Alexander Tsarouhas and Michael E. Hantes
7 Long Term Outcome of Primary Total Knee Arthroplasty.
The Effect of Body Weight and Level of Activity . . . . . . . . . . . 55
Polykarpos I. Kiorpelidis , Zoe H. Dailiana ,
and Sokratis E. Varitimidis
8 Long Term Clinical Outcome of Total Knee
Arthroplasty. The Effect of the Severity
of Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Panagiotis Megas, Anna Konstantopoulou,
and Antonios Kouzelis
9 Long Term Clinical Outcome of Total Knee
Arthroplasty. The Effect of Surgeon Training
and Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Nikolaos Roidis, Gregory Avramidis,
and Petros Kalampounias
ix
