01 Hamelynck 1

The history of Total Knee Replacement
THE HISTORY OF TOTAL KNEE REPLACEMENT
Karel J Hamelynck Amsterdam, NL
Interposition mold arthroplasty

1940 Campbell MGM arthroplasty 1941 Smith Petersen: a free-moving mold technique
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Surface replacement of the tibia
Mc Keever Mc Intosh Townley
Hinge arthroplasty
the mechanics of the knee simplified by resection of articulating surfaces and cruciate ligaments 1891: Glucks ivory total knee hinge arthroplasty
Hinge arthroplasty in the 1940s
Waldius Judet Shiers
Young
Guepar
Important innovations in arthroplasty

1960 methyl-methacrylate as a fixation material 1963 introduction of high density polyethylene plastic as a bearing surface 1971 the FDA approved of methyl-methacrylate for general use in the US
Evolution of the condylar total knee in the 1970s
knee resurfacing implants consisting of a single-piece femoral component covering both medial and lateral femoral condyles a single-piece tibial component resurfacing both medial and lateral tibial plateaus PMMA was used for fixation
Evolution of the condylar total knee in the 1970s
the patello-femoral mechanism was not necessarily included in the design: some designs had a femoral flange, patellar buttons were not used yet two philosophies - the anatomic approach - the functional approach
The anatomic approach
just the articular surfaces were replaced or resurfaced cruciate ligaments and most of the soft tissue constraints were preserved implant surfaces were designed in such a manner, that a conflict with soft tissue constraints was avoided

Polycentric knee (Gunston 1970)

Kodama-Yamamoto knee (1970)
anatomical femoral component with femoral flange minimally constrained single-piece PE tibial component with a central cutout for preservation of both cruciate ligaments

UCI knee (Waugh and Smith, 1971)
duplication of femoral condyles and tibial plateaus using casting techniques unrestricted rotational freedom

The Anatomical knee (Townley, 1971)
anatomically shaped asymmetrical femoral condyles with asymmetrical patellar flange tibial plateaus with intact menisci surfaces largely nonconforming the first prosthesis with a patellar button!

The Leeds knee (Seedhom, 1972)
anterior femoral flange with congruous patellar articulation throughout flexion no need for patellar resurfacing single-piece polyethylene tibial component with two oval concaved discs surface geometry allowing substantial anteroposterior and rotational laxity in flexion
The history of Total Knee Replacement The history of total knee replacement The anatomic approach
All anatomically designed knees had in common

the complex geometries were difficult to manufacture the surgery was considered too difficult for most surgeons most surgeons considered cruciate ligament resection necessary to correct deformity
The history of Total Knee Replacement The history of total knee replacement The functional approach
the mechanics of the knee simplified by resection of the condyles and the cruciate ligaments no attempts to be anatomical
The history of Total Knee Replacement The history of total knee replacement The functional approach
The Freeman-Swanson prosthesis(1971)

both cruciate ligaments were resected a roller-in-trough design contact areas considerably enlarged the implant seated on flat cancelous bone surfaces: no attempt was done to be anatomical!
The history of Total Knee Replacement The history of total knee replacement The Freeman-Swanson prosthesis
Frequent changes of the patellofemoral joint
The history of Total Knee Replacement The history of total knee replacement Freeman

instruments important for proper alignment flat right-angle bone cuts using intramedullary guides for both femoral and tibial cuts spacers to check gaps remaining after making bone cuts tensor device for ligament balancing
The history of Total Knee Replacement The history of total knee replacement The Hospital for Special Surgery The Hospital for Special Surgery
Duocondylar knee (1971)

Walker, Ranawat, Insall and Inglis preservation of cruciate ligaments linked femoral component separate tibial components no provision for patellar replacement
The history of Total Knee Replacement The history of total knee replacement Conclusions of the Hospital for Special Surgery
arthroplasty of the patellofemoral joint should be included preservation of both cruciate ligaments interferes with the correction of deformity cement is insufficiently contained beneath two separate tibial components: therefore fixation is insecure.
The history of Total Knee Replacement The history of total knee replacement The Hospital for Special Surgery
Duocondylar knee > Duopatella knee (Ranawat, 1974)

ACL sacrifice posterior cutout for preservation of PCL designed to solve the patellar problems of the Duocondylar knee
Duocondylar knee > Total Condylar knee (Insall, 1974)

both cruciate ligament sacrifice a troughed anterior flange and a patellar button were included the radii of the femoral and tibial components were partially conforming, to provide stability with laxity
The history of Total Knee Replacement The history of total knee replacement
PCL retention versus PCL sacrifice

HSS, New York Brigham, Boston since 1976 cruciate ligament sacrifice posterior cruciate ligament retention
The real problem however was how to provide anteroposterior stability and condylar rollback
Insall Burstein Posterior Stabilized Knee (1980)

spine & cam patella buttons conforming geometry alignment checks built into more precise instrumentation
The history of Total Knee Replacement The history of total knee replacement The PCA experience (since 1984)

Universal instruments 6 basic bone cuts flat distal condyles heat pressed UHMWPE cementless fixation porous coating on all components
The history of Total Knee Replacement The history of total knee replacement The PCA experience (since 1984)
Polyethylene wear better recognized as an important failure mechanism of total knee prostheses, due to - high contact stress on - small contact areas
The history of Total Knee Replacement The history of total knee replacement
The two most important problems of TKA mechanical loosening and wear
The history of Total Knee Replacement The history of total knee replacement The dilemma of design
Incongruent surfaces > unrestricted movements > low constraint forces > minimal loosening > high contact stresses > maximal poly wear > maximal osteolysis
The history of Total Knee Replacement The history of total knee replacement The dilemma of design
Congruent surfaces > low contact stresses > minimal poly wear > minimal osteolysis > restricted movements > high constraint forces > maximal loosening
The history of Total Knee Replacement The history of total knee replacement The Geomedic/Geometric knee (Averill, 1971)
The history of Total Knee Replacement The history of total knee replacement Surprisingly
in the 1970s and 1980s polyethylene wear was not recognized as a major cause of aseptic loosening of total knee components in a great part of the orthopaedic world
The history of Total Knee Replacement The history of total knee replacement The solution
compromise: creating more conformity between components still allowing varus-valgus rotations and some axial rotation. For many total knee systems this situation still exists today!
The history of Total Knee Replacement The history of total knee replacement OConnor and Goodfellow
first described the principle of mobile bearings with congruent contact at the femoro-tibial interface, the Oxford Knee (1976)
The history of Total Knee Replacement The history of total knee replacement Buechel and Pappas
developed a mobile bearing total knee system, the New Jersey Integrated Knee system, later called the LCS (Low Contact Stress) knee prosthesis in Newark, New Jersey, USA in 1977
The history of Total Knee Replacement The history of total knee replacement Mobile bearings in TKA
Large congruent surfaces > low contact stresses > minimal poly wear > minimal osteolysis Mobile bearings > unrestricted rotational movements > low constraint forces > minimal loosening
The history of Total Knee Replacement The future of total knee arthroplasty
What happened in the 1980s? - 1980 - DePuy introduces the LCS mobile bearing knee - Howmedica introduces the PCA total knee system 1993 - Biomet introduces the AGC total knee system 1984 - Johnson & Johnson the PFC Sigma knee - Zimmer introduces the Miller-Galante knee
The history of Total Knee Replacement The future of total knee arthroplasty What happened in the 1980s?
- 1987 - the Natural knee is introduced by Intermedics - 1989 - the Insall-Burstein II posterior stabilized knee - Howmedica introduces the Kinemax knee
- 1990 - Howmedica introduces the Duracon - 1992 - Howmedica introduces the Interax total knee system - 1993 - S&N introduces the Profix knee system (Whiteside)
-
- 1995 - Zimmer introduces the NexGen knee - Wright Medical introduces the Advance knee system 1996 - Osteonics introduces the Scorpio total knee system 1997 - the medial-pivot knee (Wright Medical)
The history of Total Knee Replacement The future of total knee arthroplasty What really happened in the 1990s?
not very much small changes of existing prostheses after changing the design it got a new name ! follow up studies were difficult to achieve
The history of Total Knee Replacement The future of total knee arthroplasty What were the issues?
fixation with or without cement polyethylene wear fixed or mobile bearings the importance of good alignment patella replacement yes or no instability of the replaced knee
The history of Total Knee Replacement The future of total knee arthroplasty Fixation with or without cement
- intrinsic constraint : the rotational forces are conducted to the bone-prosthesis interface > loosening more likely to occur
Lesson of the past freedom of anatomical movement between prosthetic components is necessary to prevent mechanical loosening
Lesson of the past freedom of anatomical movement between prosthetic components is necessary to prevent mechanical loosening Freedom of anatomical motion how?
The history of Total Knee Replacement The future of total knee arthroplasty Freedom of motion with fixed bearing knees
-
Incongruent contact areas > high contact stresses > maximal Poly wear > maximal osteolysis / loosening
The history of Total Knee Replacement The future of total knee arthroplasty Freedom of motion with fixed bearing knees
Incongruent contact areas > multi-directional movements > maximal Poly wear and osteolysis
The history of Total Knee Replacement The future of total knee arthroplasty Intra-articular movements and Poly wear
UHMWPE orientates in principle direction of sliding
(Pooley & Tabor 1972, Proc.Roy.Soc.Lon.A, 329, 251)
Strength increased parallel to sliding but reduced strength transverse to sliding

(Wang et al. 1996, Proc.IMechE, 210H, 141)
Multidirectional motion accelerates UHMWPE wear
(Wang et al. 1996, Proc.IMechE, 210H, 141)
Monodirectional motion reduces UHMWPE wear

(Marrs et al. 1999, J.Mats.Sci.Mats.Med. 10, 333)
Multi-directional motion of the femoral component relative to the tibial bearing surface in fixed bearing TKR Doubling the amount of internal-external rotation and anterior-posterior displacement produced a five-fold increase in wear rate
The history of Total Knee Replacement The future of total knee arthroplasty Freedom of motion with mobile bearing knees
- multi-directional movements are decoupled and changed into unilateral movements - wear is largely diminished
The history of Total Knee Replacement The history of total knee replacement Mobile bearings in TKA
Large congruent surfaces > low contact stresses > minimal poly wear > minimal osteolysis Mobile bearings > unrestricted rotational movements > low constraint forces > minimal loosening
The history of Total Knee Replacement The future of total knee arthroplasty Mobile bearings
- have shown excellent results in longterm clinical follow up and retrieval studies - minimal mechanical loosening - minimal wear However 80-85% of orthopedic surgeons is still using fixed bearing knee replacement systems today !!!
The history of Total Knee Replacement The future of total knee replacement Good mechanical alignment
What are we doing? - is this the mechanical axis ?
What are we doing ? - our bone cuts are not anatomical !! - where is the mechanical axis ?
Do we need computer assisted surgery (CAS) to malalign our knees more precisely?
The history of Total Knee Replacement The future of total knee replacement Replacing the patella yes or no?
- to ensure good patellar tracking is more important than patellar replacement
- para-patellar release
- contouring the patella
- geometry of the femoral component plays an important role
Femoral Design in TKA
The history of Total Knee Replacement The future of total knee replacement
The problem of instability
Why are total knee arthroplasties failing today?

Peter F. Sharkey, MD; William J. Hozack, MD; Richard H. Rothman, MD, PhD; Shani Shastri, MD; Sidney M. Jacoby, BA. CORR Nov 2002:7-14
Current etiologies and modes of failure in revision TKA
Kevin J. Mulhall, Hassan M. Ghomrawi, Sean Scully, John J. Callighan, Khaled J. Saleh Clinical Orthopaedics and Related Research 446, pg 45-50, 2006
The history of Total Knee Replacement The future of total knee arthroplasty Lessons learned from revision surgery
polyethylene wear is the most important reason of failure in long term follow up insufficient surgery is the most important reason for failure in short term follow up instability has become an important reason for revision
The history of Total Knee Replacement The Thefuture futureof oftotal totalknee kneearthroplasty arthroplasty Instability why?
During TKA - removal of the articular surfaces - cruciate ligament resection. And we expect that knee to be stable?
Stability of the knee is a DYNAMIC process guided by proprioception
The history of Total Knee Replacement The future of total knee replacement It is even worse:
after cruciate ligament resection > release of a collateral ligament to correct deformity we are disregarding the negative consequences of collateral ligament release to achieve a perfect (?) alignment
The consequences of collateral ligament release
the mechanical stability provided by the ligaments is diminished the proprioceptiv function of the ligaments is destroyed > dynamic stability of the knee disturbed
The stability of the knee is a dynamic process

muscle force guided by the central and peripheral nerve system guided by proprioception
The principle of todays TKA It is mandatory to maintain the collateral frame of condyles and collateral ligaments to keep the knee stable
If some residual deformity is still present

not releasing the collateral ligaments should probably prevail over release in order to support the stability of the knee
instability is created by the surgeon !!!
The history of Total Knee Replacement The future of total knee replacement Do I need to talk about?
- gender specificity - minimally invasive surgery - high flexion knees
The history of Total Knee Replacement The future of total knee replacement Total knee replacement today
- is a very successful procedure - however we are still making too many mistakes - too many patients are not happy with their new knee - why so-called perfect knee replacements are painful?
The history of Total Knee Replacement The future of total knee replacement Total knee replacement today
- we need to become better surgeons we need to get a more physiological TKA avoid collateral ligament release cruciate ligament retention in selected cases use mobile bearings
The history of Total Knee Replacement The future of total knee replacement Different prostheses
in different pathologies and different patients, just replacing what is necessary and preserving what is needed
Thank you

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The history of Total Knee Replacement

THE HISTORY OF TOTAL KNEE REPLACEMENT

Karel J Hamelynck Amsterdam, NL

The history of Total Knee Replacement

Interposition mold arthroplasty

The history of Total Knee Replacement

Surface replacement of the tibia

Mc Keever Mc Intosh Townley

The history of Total Knee Replacement

The history of Total Knee Replacement

Hinge arthroplasty in the 1940s

Waldius Judet Shiers

The history of Total Knee Replacement

Important innovations in arthroplasty

The history of Total Knee Replacement

The history of Total Knee Replacement

The history of Total Knee Replacement

Evolution of the condylar total knee in the 1970s

The history of Total Knee Replacement

Evolution of the condylar total knee in the 1970s

The history of Total Knee Replacement

The anatomic approach

The history of Total Knee Replacement

The anatomic approach

The history of Total Knee Replacement

The anatomic approach

The history of Total Knee Replacement

The anatomic approach

The history of Total Knee Replacement

The anatomic approach

The history of Total Knee Replacement

The anatomic approach

PCL retention versus PCL sacrifice

Strength increased parallel to sliding but reduced strength transverse to sliding

Monodirectional motion reduces UHMWPE wear

Femoral Design in TKA

The problem of instability

Why are total knee arthroplasties failing today?

Stability of the knee is a DYNAMIC process guided by proprioception

The history of Total Knee Replacement

The consequences of collateral ligament release

The history of Total Knee Replacement

The stability of the knee is a dynamic process

The history of Total Knee Replacement

If some residual deformity is still present

instability is created by the surgeon !!!

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