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The Journal of Arthroplasty Vol. 18 No. 3 Suppl.

1 2003

Constraint in Total Knee Arthroplasty


When and What?

James P. McAuley, MD, FRCSC, and Gerard A. Engh, MD

Abstract: Tibiofemoral instability is increasingly recognized as a common mode of


failure in total knee arthroplasty. Despite this, there are few published guidelines
concerning treatment options, component selection, and expected results. In the
treatment of the unstable total knee arthroplasty, cruciate-retaining designs can be
considered only in the presence of well-balanced ligaments, including the posterior
cruciate ligament. More predictable results are obtained with the use of cruciate-
substituting components, but they provide no varus-valgus stability and cannot
compensate for severe flexion laxity. Varus-valgus constrained designs cannot pro-
vide long-term stability in cases of varus-valgus instability or severe flexion laxity.
Such cases are most reliably treated with a linked implant. Key words: total knee
arthroplasty (TKA), instability, revision.
© 2003 Elsevier Inc. All rights reserved.

The goals of any revision knee procedure must important to plan the reconstruction of bone defi-
include reconstruction of bone deficiency and stable ciency and determine the appropriate augments or
fixation of the components to the underlying bone. stems needed to obtain stable, durable fixation.
Also important for a functional and durable revision Easily forgotten is the importance of a careful eval-
is restoration of knee stability. With many choices uation of knee stability. The need to restore stability
of component designs and levels of constraint, it during knee revision cannot be overstated. The
can be a very difficult process to select the optimum preoperative plan, therefore, must also provide for
implant for a given patient. The purpose of this restoration of stability using the required degree of
paper is to provide simple guidelines to facilitate component-to-component constraint. During the
component selection for knee instability, an area revision procedure, systematic evaluation of the
that is still incompletely understood. adequacy and balance of the soft tissue envelope
greatly simplifies the selection of the appropriate
implant.
Preoperative Planning

Templating of preoperative radiographs is a fa- Cruciate-Retaining Implants


miliar process to most arthroplasty surgeons. It is
Cruciate-retaining designs represent the least
amount of component constraint, and their success
From the Anderson Orthopaedic Research Institute, Alexandria, depends on a sound biomechanical environment.
Virginia. This translates to the presence of good-quality bone
No benefits or funds were received in support of this study.
Reprint requests: James P. McAuley, MD, FRCSC, c/o Rebecca with minimal defects, intact soft tissues, and a pos-
Wolf, Anderson Orthopaedic Research Institute, PO Box 7088, terior cruciate ligament (PCL) that remains func-
Alexandria, VA 22307. tional and balanced. This represents a relatively rare
© 2003 Elsevier Inc. All rights reserved.
0883-5403/03/1803-1014$30.00/0 situation, such as a previous PCL-retaining proce-
doi:10.1054/arth.2003.50103 dure with minimal bone loss. This can occur in

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52 The Journal of Arthroplasty Vol. 18 No. 3 Suppl. 1 April 2003

cases of polyethylene insert wear with intact com-


ponents, early failure of fixation, or in revision of
failed unicompartmental arthroplasty.
For example, in the Anderson Clinic series of revi-
sions of failed unicompartmental knees, cruciate-re-
taining femoral components were used in 80% of
cases [1]. Conversely, in most revision situations, cru-
ciate-retaining implants are not indicated. For exam-
ple, the presence of a loose flexion space and a defi-
cient PCL is not appropriate for retaining designs.
Such a combination often fails because of recurrent
posterior instability (Fig. 1)[2,3].

Cruciate-Substituting Implants
The next level in constraint is cruciate substitu-
tion. What is gained? Obviously this design me-
chanically substitutes for PCL function. Because all
the technical and judgment issues of balancing the
PCL are eliminated, many people find this option
easier and more forgiving. Fig. 2. Photograph of a cruciate-substituting knee, which
Equally important, however, is recognizing what does not provide varus-valgus stability.
is not gained with PCL-substituting designs. There is
no gain in varus-valgus stability (Fig. 2), and real-
istically speaking, minimal rotational stability.
Thus, for a posterior-stabilized implant to succeed, a
Another reported option for providing posterior
functional soft tissue envelope is needed to provide
stability in the absence of a functioning PCL is the
varus-valgus stability. However, the need for good
use of an “ultracongruent” tibial insert [5]. With
flexion-extension balancing is also important. With
this concept, posterior stability is provided by a
a residually loose flexion space, the femoral com-
12.5-mm buildup of the anterior tibial insert, rather
ponent can ride up on the tibial post (Fig. 3) and
than the post and cam mechanism of traditional
result in posterior tibiofemoral dislocation [4].
posterior-stabilized implants. This has been used
successfully in both primary and revision knee ar-
throplasty [5]. Clearly, the same requirements for
varus-valgus stability and adequate flexion-exten-
sion balancing apply to this concept as well.

Varus-Valgus–Constrained Implants
The next level of constraint is varus-valgus con-
straint. Such components provide a significant de-
gree of rotational control, and more significantly, a
great deal of constraint to varus-valgus angulation.
The trade-off is the theoretical disadvantage of in-
creased stress transmission to the component– bone
interfaces. Despite this, at least in the short term,
the results seem comparable to less constrained
designs [6 –10]. However, in the longer term, the
results may not be quite as encouraging [11].
One must not forget that severe flexion instability
is still a limitation for varus-valgus constrained im-
plants. Despite the taller tibial post in these designs,
the implant can still jump posteriorly in the pres-
Fig. 1. Lateral radiograph shows posterior subluxation of ence of severe flexion space laxity, resulting in
the tibia. posterior dislocation of the knee (Fig. 4).
Constraint in Total Knee Arthroplasty • McAuley and Engh 53

implant) has historically produced disappointing re-


sults, predominantly because of implant loosen-
ing [12,13] .
Despite less rotational constraint with rotating
hinges, results with early series of these hinges have
not shown much better results, with disappointing
clinical outcomes and high complication rates [14].
However, newer designs of rotating hinges have
produced more encouraging clinical and radio-
graphic results [15,16].
Therefore, the indications for a hinged compo-
nent continue to evolve, the strongest indications
being the absence of medial collateral soft tissue
support and severe flexion instability. Relative in-
dications include neuropathic joints and elderly,
low-demand patients who have a poor soft tissue
envelope. With major structural revisions, such as
allograft prosthetic composites, one would predict
the need for constrained devices. However, the
required degree of constraint depends on the soft
tissue envelope, not on the pre-existing bone defi-
ciency. When the capsule and collateral ligaments
are maintained, they can provide extension stabil-
ity. Flexion stability can be restored with reattach-
ment of the collaterals, so surprisingly little compo-
Fig. 3. Diagram of the mechanism of posterior dislocation nent constraint may be necessary.
of the tibial post under the femoral cam, which can occur In summary, in cases of instability or severe de-
with flexion instability.
formity, constrained components must be available.
In the presence of severe flexion-extension mis-
match or deficient medial stabilizing soft tissues, a
Because these implants limit varus-valgus angu- rotating hinge design should be considered.
lation between the femoral and tibial components, Instability is increasingly recognized as a major
it would seem intuitive that they could be used in factor in failures of primary and revision knee ar-
cases of severe medial or lateral instability. Unfor-
tunately, our experiences and those of others have
shown poor results in treating both medial and
lateral instability with varus-valgus constrained im-
plants. In the Anderson Clinic experience, attempts
at revision for severe varus or valgus instability
were successful in only 2 of 10 cases. The mode of
failure was late recurrence of the instability.
Simply stated, the post of a varus-valgus con-
strained knee cannot be expected in isolation to
provide stability in the long term. However, the
post can provide short-term support for healing
collateral structures or in association with collateral
reconstruction.

Linked (Hinged) Designs


For the reasons stated earlier, less constrained
components have severe limitations in the absence
of collateral soft tissue support or in the presence of
gross flexion extension instability. Unfortunately, Fig. 4. Lateral radiograph of posterior dislocation of a
going to the highest degree of constraint (a hinged varus-valgus constrained knee.
54 The Journal of Arthroplasty Vol. 18 No. 3 Suppl. 1 April 2003

ion instability after primary cruciate retaining total


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