Professional Documents
Culture Documents
1 2003
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
51
52 The Journal of Arthroplasty Vol. 18 No. 3 Suppl. 1 April 2003
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