Constraint in Primary Total

Knee Arthroplasty

Hannah Morgan, MD, Abstract

Vincent Battista, MD, and
Seth S. Leopold, MD
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Instability is an important cause of failure following total knee
arthroplasty. Increasing component constraint may reduce
instability, but doing so also can cause increased forces to be
transmitted to fixation and implant interfaces, which may lead to

premature aseptic loosening. Constraint is defined as the effect of

Dr. Morgan is Acting Instructor,
Department of Orthopaedics and Sports
Medicine, University of Washington
Medical Center, Seattle, WA. Dr.
Battista is Assistant Program Director,
Orthopaedic Surgery Residency
Program, William Beaumont Army
Medical Center, El Paso, TX. Dr.
Leopold is Associate Professor,
Department of Orthopaedics and Sports
Medicine, University of Washington
Medical Center.
the elements of knee implant design that provides the stability
needed to counteract forces about the knee after arthroplasty in the
presence of a deficient soft-tissue envelope. Determining the
amount of constraint necessary can be challenging. Most primary
total knee arthroplasties are performed for knees without
substantial deformity or the need for difficult ligament balancing;
in these cases, either a posterior-stabilized or a posterior cruciate–
retaining design is appropriate. In certain situations, such as
patients with prior patellectomies, rheumatoid arthritis, or
substantial preoperative deformities, a posterior-stabilized knee
may be favored. With their large posts, varus-valgus constrained
implants typically are reserved for patients with substantial
coronal plane instability, which is difficult to balance with a
posterior-stabilized or cruciate-retaining implant alone. Rotating-
hinge knee implants usually are recommended for patients with
severe deformity or instability that cannot be managed with a
varus-valgus implant.

The views expressed in this manuscript

are those of the authors and do not
reflect the official policy of the
Department of Defense or the United
States Government.
Reprint requests: Dr. Seth S. Leopold,
University of Washington Medical
Center, 1959 NE Pacific Street, Box
356500, Seattle, WA 98195.
J Am Acad Orthop Surg 2005;13:515-
524
Copyright 2005 by the American
Academy of Orthopaedic Surgeons.
S uccessful outcomes with total
knee arthroplasty (TKA) depend
on many factors, one of which is the
degree of constraint inherent in the
prosthesis design. Constraint is de-
fined as the effect of the elements of
knee implant design that provide the
stability needed in the presence of a
deficient soft-tissue envelope. In two
recent reports, in which a total of
nearly 500 failed TKAs were exam-
ined, instability was the cause of
nearly 25% of all the total knee revi-
sions performed.1,2
Instability occurs when the avail-
able ligaments and soft-tissue struc-
tures, in combination with the pro-
thesis articular design and limb
alignment, are unable to provide the
stability necessary for adequate
function in the presence of stresses
transmitted across the knee joint. In-
stability may be the result of gener-
alized soft-tissue laxity, inadequate
flexion/extension gap balancing, im-
proper component position or align-
ment, or ligamentous insufficiency.
Such instability may occur in any
plane.
To address instability in primary
TKA, implants with varying degrees
of constraint are available. These

Volume 13, Number 8, December 2005 515

Constraint in Primary Total Knee Arthroplasty
range from flat-on-flat, posterior cru-
ciate ligament (PCL)–retaining, un-
constrained articulations to fully
linked, maximally constrained, sim-
ple hinge designs. However, the add-
ed degrees of implant stability carry
potential, and sometimes actual, dis-
advantages. As the amount of con-
straint is increased, stress transmit-
ted to the modular implant-host or
prosthesis-host interface also in-
creases. The heightened stress may
result in increased backside polyeth-
ylene wear in modular tibial compo-
nents or in early implant loosening,
and ultimately to failure.3 Most au-
thors therefore recommend using
the least amount of implant con-
straint necessary to achieve a satis-
factory result.4
Constraint Terminology
and General Principles
Little standardization exists in the
terminology used by implant manu-
facturers and surgeon-investigators to
describe the degree of constraint
within a particular arthroplasty de-
sign. Furthermore, many studies
substitute brand-specific names for
descriptive generic terminology,
adding to the difficulty of comparing
designs. The major implant categor-
ies in present use, from the least to
the most constrained, are as follows:
(1) PCL-retaining (often called
cruciate-retaining, or CR); (2) PCL-
substituting (often called posterior-
stabilized, or PS); (3) unlinked con-
strained (sometimes called varus-
valgus constrained, or VVC); and (4)
rotating-hinge knee implants. Com-
mon brand-specific terms for the VVC
design include the NexGen Legacy
Constrained-Condylar Knee (Zim-
mer, Warsaw, IN) and the Total
None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a
commercial company or institution related directly or indirectly to the subject of this article: Dr. Morgan and Dr. Battista. Dr. Leopold or the
department with which he is affiliated has received research or institutional support from Zimmer, Inc. Dr. Leopold or the department with which
he is affiliated has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related
funding (such as paid travel) from Zimmer, Inc. Dr. Leopold or the department with which he is affiliated serves as a consultant to or is an
employee of Zimmer, Inc.
516
Condylar III (Johnson & Johnson,
Braintree, MA). Both are unlinked,
constrained prosthetic alternatives to
rigid or rotating-hinge prostheses for
complex knee reconstructions in
which additional coronal-plane stabil-
ity is desired because of soft-tissue de-
ficiencies.
Cruciate-Retaining
Implants
CR (PCL-retaining) implants are
minimally constrained prostheses
that depend on an intact PCL to
limit posterior translation of the tib-
ia on the femur. Potential benefits of
CR implants (over either PCL-
sacrificing or PCL-substituting de-
signs) include the following: fewer
patellar complications, increased
quadriceps muscle strength, im-
proved stair-climbing ability, pre-
served proprioceptive fibers, lowered
shear forces at the tibial component–
host interface, improved bone-stock
preservation on the femoral side, and
retention of more nearly normal
knee kinematics. In addition, CR
implants avoid the tibial post–cam
impingement or dislocation over the
tibial post that can occur in PS
implants.5-7
Posterior-Stabilized
(Cruciate-Substituting)
Implants
In contrast with CR implants, PS
(PCL-substituting) implants have de-
sign features (eg, a tibial post and
femoral cam, deeply “dished” artic-
ular surfaces, and a “third condyle”)
that limit excessive tibial transla-
tion of the knee arthroplasty after re-
section of the PCL (Figure 1). By al-
lowing rollback, increasing the
amount of distraction tolerated be-
fore subluxation occurs, and increas-
Journal of the American Academy of Orthopaedic Surgeons
ing varus-valgus constraint, the
cam-post mechanism improves both
anterior-posterior and translational
stability.
Recently, interest has developed
in using highly conforming tibial in-
serts to increase stability.8 Some de-
signs may eliminate the need for re-
section of intercondylar notch bone
stock and the use of a tibial post,
which has the potential to wear.
Various methods of achieving poste-
rior stability are used by each im-
plant design, with theoretic benefits
to each design. However, no com-
parative clinical studies confirm the
superiority of one design over an-
other.
Regardless of the method used to
achieve posterior stability, there are
reported intraoperative and postop-
erative benefits of a PS prosthesis
over a CR design. These benefits in-
clude relative ease of ligament bal-
ancing, greater versatility in the
presence of different types of knee
deformity, easier correction of severe
deformity by eliminating a tight
PCL, increased predictability in res-
toration of knee kinematics, im-
proved range of motion, and poten-
tially minimized polyethylene wear
because of the option to use more
congruent articular surfaces.8-11 Fur-
thermore, the PCL can rupture post-
operatively when it is overzealously
recessed intraoperatively, is tight
postoperatively because of an altered
joint line, or is damaged by synovitis
from inflammatory arthropathy, re-
sulting in failure.9 The use of PS im-
plants avoids these problems.
A potential problem with PS im-
plants, however, is tibial post poly-
ethylene wear from the cam-post
mechanism. Excessive wear particu-
late debris can lead to osteolysis.
 Hannah Morgan, MD, et al

Figure 1 Figure 2

Varus-valgus constrained implant

(Maximum Constrained Knee). These
implants feature a tibial post that
engages in a deep femoral box to
provide stability. (Courtesy of Biomet,
Warsaw, IN.)

Varus-Valgus Constrained
Implants
VVC implants have a tall (often re-
inforced) tibial post and a deep fem-
oral box, which provide more inher-
ent coronal plane stability than do PS
prostheses (Figure 2). Because there is
no axle connecting the tibial and fem-
oral components, these implants are
sometimes referred to as unlinked
constrained implants. To a variable
A through D, Sagittal plane kinematics of a posterior-stabilized total knee extent, depending on design, VVC im-
arthroplasty. The tibial post engages a femoral box during knee flexion, substituting
plants limit varus-valgus tilt as well
for the resected posterior cruciate ligament and providing posterior stability during
as rotation (Figure 3). The stem exten-
gait. However, the polyethylene on the tibial post can be a source of wear or
impingement, and dislocation over the post (when the flexion-extension gaps are sion is important in transmitting
not balanced) can cause failure of the TKA. (Courtesy of Zimmer, Warsaw, IN.) stresses generated by the constrained
articulation away from the fixation
interfaces at the joint line to more
normal diaphyseal bone (cementless
This problem especially occurs in box and keel, and the risk of disloca- stems) or along a broader surface area
implant designs with fixed femoral tion or instability in flexion.6,12 of implant-cement-bone contact (ce-
components and a posterior tibial Despite the dissimilarities be- mented stems).
slope. Another disadvantage of PS tween CR and PS implants, most VVC knee implants may be used
implants is soft-tissue impingement, studies have found no significant for both primary and revision arthro-
including the patellar “clunk” syn- differences in function, patient sat- plasty. They are often helpful in
drome, in which a soft-tissue nodule isfaction, or survivorship of the treating patients with severe valgus
forms that can wedge into the intra- two designs in unselected patient deformities, collateral ligament defi-
condylar notch during knee flexion, cohorts.13-15 However, CR and PS im- ciency, bone defects, and residual in-
causing an audible and painful plants may not function similarly in stability or irreconcilable flexion-
“clunk.” Other disadvantages in- particular subgroups of patients (eg, extension imbalances after PS
clude potential raising of the joint patients with patellectomy, rheuma- implants. These implants have an
line, the need for additional bone re- toid arthritis, or large varus or varus- acceptable survival rate at interme-
section to accommodate the femoral flexion deformity). diate follow-up, but little is known

Volume 13, Number 8, December 2005 517

Constraint in Primary Total Knee Arthroplasty

Figure 3 Figure 4

Rotating-hinge implant. In these

prostheses, sometimes called “linked
constrained” devices, femoral and tibial
components are united by an axle that
defines the flexion-extension arc in
the sagittal plane. (Courtesy of Biomet,
Warsaw, IN.)

oral components are linked with an

axle that restricts varus-valgus and
translational stresses (Figure 4). To de-
crease the overall amount of con-
straint, these components permit ro-
tation of the tibial bearing around a
yoke on the tibial platform. This con-
figuration provides a great degree of
inherent stability; for that reason,
these implants are very useful in sal-
Anteroposterior (A) and lateral (B) views demonstrating stability of a varus-valgus vage situations (eg, significant bone
constrained total knee arthroplasty. This drawing depicts the degree of coronal loss, severe deformity, unreconstruc-
plane and rotational constraint provided by the tall, wide tibial spine in the deep table ligamentous deficiency, flexion/
femoral box of a VVC device. Most VVC implants are similar and permit 2° to 3° of extension gap imbalances).
varus-valgus stability and approximately 2° of internal-external rotation. (Courtesy of Historically, aseptic loosening was
Zimmer, Warsaw, IN.) seen more commonly in uniplanar
hinged knee devices because of the
tremendous degree of constraint,
about their performance beyond 10 nence.4 However, regardless of the which prohibited rotational motion.
years.16-19 potential problems, VVC implants These are no longer in use. The poten-
Drawbacks of VVC implants in- remain an important tool in the ar- tial drawback still exists of forces ap-
clude the need to remove femoral in- mamentarium of the surgeon who plied across the knee being transmit-
tercondylar bone to accommodate performs knee arthroplasties. ted to the constraining portions of the
the femoral box, which decreases the implant or to implant-bone interfaces,
remaining bone stock available for Rotating-Hinge Knee leading to aseptic loosening or to un-
revisions, and potentially higher Implants usual mechanisms of prosthesis fail-
rates of aseptic loosening as a result Rotating-hinge knee implants are ure.4,21 However, the long-term dura-
of increased constraint.16 Other po- highly constrained devices most of- bility seen in younger oncology
tential drawbacks are failure or frac- ten used for complex revision arthro- patients suggests that the rotating
ture of the tibial intercondylar emi- plasty performed for severe bone loss hinge can dissipate some of the forces.
nence20 and recurrent instability and/or complex instability and for on- Another drawback to rotating-
despite an intact intercondylar emi- cologic surgery. The tibial and fem- hinge knee implants is that a larger

518 Journal of the American Academy of Orthopaedic Surgeons

 Hannah Morgan, MD, et al

bone resection is necessary to accept Figure 5

the housing of the implant. This is a
concern because of both the reduced
amount of bone supporting the pros-
thesis and the potential difficulties
that could be encountered with future
revision procedures. As a result of
these issues, many knee surgeons rec-
ommend a hinged knee prosthesis
only for patients with severe collat-
eral ligament insufficiency, for those
with marked bone loss, in compli-
cated salvage cases, or in elderly pa-
tients with comminuted fractures
around the joint.22,23 Long stems are
required on the femoral side in these
implants to limit the stress placed on
the interfaces at the joint line and to
transmit the stresses away from fix-
ation interfaces, typically to diaphy-
seal bone.

Management
The surgeon must decide, based on
patient factors and the type of knee
deformity, how much constraint is
necessary for the primary TKA pa-
tient. The degree of actual or poten-
tial instability should be assessed,
and the least-constrained implant
that will correct that instability
should be chosen (Figure 5).

Uncomplicated Primary
Total Knee Arthroplasty
The typical patient undergoing an
index knee replacement has mild or
moderate coronal plane deformity,
intact posterior cruciate and collat-
eral ligaments, adequate bone stock,
and a normal extensor mechanism.
In these patients, either a CR or PS
implant may be chosen; both exhibit
apparently similar survivorship into
the second decade.
As previously noted, the potential Algorithm for selecting degree of constraint in primary total knee arthroplasty. CR =
benefits of a CR implant include posterior cruciate–retaining, MCL = medial collateral ligament, PCL = posterior
femoral bone preservation, tibial cruciate ligament, PS = posterior stabilized (PCL-substituting), TKA = total knee
bone preservation (when pegs are arthroplasty, VVC = varus-valgus constrained (unlinked constrained)
used instead of a keel or stem to aug-
ment cemented fixation), the possi-
bility of more nearly normal knee tages of a CR prosthesis include symmetry because of the additional
kinematics, and some native varus- the potential for greater difficulty ligament (PCL) that must be bal-
valgus stability.24,25 The disadvan- achieving flexion and extension gap anced, as well as the potential for in-

Volume 13, Number 8, December 2005 519

Constraint in Primary Total Knee Arthroplasty
creased polyethylene wear when the
PCL is too tight postoperatively.
When the PCL is sectioned and a PS
component is used, ligament balanc-
ing is less difficult and may be more
reliable. PS devices are versatile and,
therefore, may be used in patients
with more complex deformities. For
these reasons, familiarity with PS
designs may be useful for surgeons
who perform joint replacements
only occasionally and require a sin-
gle, versatile surgical technique.
Severe Varus Deformity
With Collateral Ligaments
Intact
Although a severe varus defor-
mity may occur in isolation, more
commonly it occurs in combination
with a flexion contracture.10 In the
presence of such a deformity, deter-
mining the degree of prosthesis con-
straint is important. Equally impor-
tant, however, is addressing the
deformity and ligament contractures
themselves.
One of the risks in patients with
severe preoperative varus deformity
is that the knee will retain some re-
sidual varus postoperatively.26 Be-
cause of this tendency, various tech-
niques to correct varus deformity
and to balance ligaments intraoper-
atively have been described. Laskin
and Schob27 reported on medial cap-
sular recession, a procedure in which
the medial capsular flap is elevated
distal to the pes anserinus and al-
lowed to slide as the knee is stressed
into valgus. This aggressive medial
soft-tissue release allows correction
of the deformity and ligament bal-
ancing without leading to postoper-
ative instability. Laskin and Schob27
also emphasized that the PCL is of-
ten contracted in patients with se-
vere varus, further contributing to
the deformity. A medial release
alone may not correct the flexion
and varus contractures; therefore, a
PCL release and subsequent use of a
PS implant may be necessary to
avoid the higher incidence of postop-
erative pain, radiolucencies, reduced
520
flexion, and increased need for revi-
sion that accompany a retained, con-
tracted PCL.10
A medial epicondylar osteotomy
is another method of achieving ade-
quate soft-tissue release in a severe
varus knee. In contrast to other tech-
niques that involve extensive sub-
periosteal stripping, this procedure
avoids ligament damage. Engh and
Ammeen28 reported excellent pa-
tient satisfaction, stability, motion,
and deformity correction. Regardless
of the technique used, the varus de-
formity must be corrected, and bal-
ance of the coronal plane ligament
must be reestablished to minimize
the likelihood of premature failure
of the TKA.
Most unselected cohort series (in
which most patients have varus de-
formities) have shown excellent re-
sults into the second decade of im-
plant survivorship, with either CR
or PS implants. However, only one
study10 that compares CR and PS
implants has been performed in the
context of severe varus or varus-
flexion deformities. In this series,
Kaplan-Meier survivorship, range of
motion, and pain-related outcomes
were worse in patients with fixed
varus (or varus-flexion) deformities
>15° who were treated with CR de-
vices, compared with patients treat-
ed with PS implants or with those
who did not have such varus defor-
mities and were treated with CR de-
vices.10
Severe Valgus Deformity
With Collateral Ligaments
Intact
Patients may present with a val-
gus deformity that resulted from
lateral compartment bone loss and
soft-tissue contracture, medial col-
lateral ligament (MCL) attenuation,
or overcorrected proximal tibial os-
teotomy. The major concern, and
the focus of the preoperative assess-
ment of the valgus knee, should be
the status of the MCL. It may be nor-
mal, attenuated but present, or ab-
sent.
Journal of the American Academy of Orthopaedic Surgeons
The surgical treatment of these
knees depends on the type and de-
gree of deformity and the condition
of the MCL. When the MCL is
present and functional, either a CR
or PS implant may be used. Howev-
er, similar to the tight varus knee,
before the level of constraint is se-
lected, it is essential to balance the
knee in the coronal plane. Regard-
less of which implant is chosen,
when the MCL is intact, then resto-
ration of the mechanical axis to neu-
tral, releases of lateral-sided struc-
tures (as appropriate), and placement
of a suitably sized polyethylene in-
sert usually suffice to correct the de-
formity and balance the knee.
Numerous descriptions of step-
wise techniques for performing lat-
eral releases and ligament balancing
have been published.29,30 Most rec-
ommend evaluating the knee both
in flexion and extension and sequen-
tially approaching the tight struc-
tures in each position. A selective
lateral release of the lateral retinac-
ulum and iliotibial band and of the
posterior capsule may be performed
as necessary. Release of the popli-
teus tendon and release or advance-
ment of the lateral collateral liga-
ment also may be performed in
severe cases. In addition, externally
rotating the tibial baseplate to inter-
nally rotate the tibial tubercle may
help patellar tracking in the patient
with a valgus deformity.
A VVC implant may be chosen
for patients who present with severe
deformity, especially when the me-
dial structures are attenuated or
when the patient is elderly.17 Regard-
less of the technique used, it is es-
sential that the mechanical axis be
restored to normal to avoid the poor
clinical outcomes that may result
from patellar maltracking or coronal
plane instability, seen in patients
with residual excess valgus postop-
eratively.
Although uncommon, patients
with severe deformity and/or severe
ligament insufficiency may have
complex instability present in both

flexion and extension. This instabil-
ity exceeds the typical coronal plane
laxity observed in the MCL-deficient
knee; a far more constrained implant
is required to gain satisfactory stabil-
ity at the time of arthroplasty. This
complex instability is usually a re-
sult of sequelae from severe trauma
or the multiply operated knee. Be-
cause the stems of VVC implants
may not withstand forces generated
by knees with severe varus-valgus
laxity, a rotating-hinge knee implant
may be the best option in these pa-
tients. However, only limited pub-
lished follow-up is available regard-
ing contemporary rotating-hinge
designs at intermediate follow-up or
longer for this clinical setting;31
therefore, the decision to use a
hinged implant should be carefully
considered.
Patients With Rheumatoid
Arthritis
Patients with rheumatoid arthri-
tis present special concerns for the
surgeon, not only because of medi-
cal, anesthetic, and associated mus-
culoskeletal problems, but also be-
cause of the tendency for generalized
ligamentous laxity or attenuation
and joint deformity. These patients
may present with severe or fixed val-
gus deformities.
Most patients with rheumatoid
arthritis present with minimal coro-
nal plane deformity. Whether a CR
or PS implant is more prudent in
these patients is controversial be-
cause of concerns about the typical-
ly poor quality of the soft tissues and
the potential for synovitis to cause
late attenuation and rupture of the
PCL. Although some have reported
excellent results with a CR prosthe-
sis at intermediate follow-up, 32 con-
cern exists that late instability may
occur with long-term follow-up.
Hanyu et al33 assessed the PCL intra-
operatively and performed CR TKA
in patients only when the PCL was
present and functioning normally. In
their series, 10-year survivorship of
the entire TKA cohort (both CR and
Volume 13, Number 8, December 2005
PS) was 93%. No revisions were per-
formed for instability in the CR
group, whereas 6.5% of TKAs in the
PS group (2/31) developed late dislo-
cations (at 8 and 10 years postopera-
tively) over the tibial post.33
In another retrospective study,
CR implants in patients with rheu-
matoid arthritis were associated
with inferior results compared with
PS implants, principally because of
late instability and progressive re-
curvatum deformity.34 Although the
authors concluded that a PS implant
is more appropriate in the setting of
rheumatoid arthritis to avoid these
complications, they did not com-
ment on the extent of the synovitis
or the integrity of the PCL at the
time of the index arthroplasty.
Patients With Patellectomy
Patellectomy leads to the disrup-
tion of the normal four-bar linkage
of the knee. In the context of knee
replacement, it has been hypothe-
sized that loads on the PCL in the
years following surgery may be in-
creased, potentially resulting in late
attenuation and instability.11,35,36 Pa-
tellectomy also can cause decreased
extensor mechanism power because
of the loss of the fulcrum provided
by the intact patella. A retrospective
study showed that patellectomized
patients treated with PS implants
had better functional and pain scores
than did those treated with CR im-
plants.11 The observation that use of
PS devices leads to better results
when TKA is performed in patients
with prior patellectomies has been
supported.35 However, it is impor-
tant to note that TKA patients with
prior patellectomies generally have
poorer outcomes and higher compli-
cation rates than do nonpatellecto-
mized patients, even when PS im-
plants are used.36
Medial Collateral Ligament
Deficiency and Total Knee
Arthroplasty
Deficiency and instability of the
MCL can create a great challenge for
Hannah Morgan, MD, et al
the surgeon performing an arthro-
plasty. A wide spectrum of MCL at-
tenuation and functional laxity ex-
ists, ranging from mild valgus
deformities with no ligament atten-
uation to severe valgus deformity
with ligament attenuation or rup-
ture. Many factors, such as patient
age, activity level, host tissue com-
promise (ie, rheumatoid arthritis),
bone-stock deficiency, and multiple
prior knee surgeries, influence the
choice of surgical technique and im-
plant in a patient with an MCL-
deficient knee. The diagnosis of an
MCL-deficient knee should be made
preoperatively so that the range of
necessary implants is available at
the time of surgery. The amount of
valgus deformity should be noted, as
well as the degree of MCL instabili-
ty. A high index of suspicion that the
MCL may not be competent should
be maintained in patients with
marked valgus deformity or a predis-
posing history (eg, rheumatoid ar-
thritis, prior osteotomy).
Choice of Implant
In a knee with only a mild valgus
deformity and ligament attenuation,
either a CR or PS implant design
may be used. Most authors agree
that PS TKA components should be
used when the PCL needs to be sac-
rificed to obtain appropriate soft-
tissue balance. In cases of grade 2 or
lower MCL laxity, the extremity
alignment can be corrected so that
the lax compartment is loaded and
closed with weight bearing. In this
way, the varus-valgus constraint
mechanism is not overtaxed. White-
side,37 Healy et al,38 and Krackow et
al39 reported success in treating mild
to moderate MCL laxity with CR
implants, ligament balancing, and
proximal MCL advancement when
needed.
When the MCL ligament demon-
strates moderate attenuation or
when substantial valgus deformity
exists, either a PS or VVC implant
may be used. A number of se-
ries16,18,19 have demonstrated accept-
521
Constraint in Primary Total Knee Arthroplasty
able results with a VVC implant,
generally without specific repair or
reconstruction of the MCL; excel-
lent or good outcomes in 80% of pa-
tients at intermediate follow-up
have been reported. In patients with
severe MCL attenuation, especially
those with complex instability in ad-
dition to coronal plane laxity, either
a VVC or a rotating-hinge implant
usually is required, especially when
the patient is not a candidate for
MCL reconstruction.
Medial Collateral Ligament
Repair or Reconstruction
Advancement, imbrication, or al-
lograft reconstruction of the MCL
may be done to treat medial-sided
laxity, often in conjunction with a
VVC implant. Advantages of imbri-
cation or advancement include the
potential for increased component
survivorship because of decreased
stress transmission to the fixation
surfaces and avoidance of allograft
tissue, as would be needed for liga-
ment reconstruction. Disadvantages
of this technique include the poten-
tial for late attenuation or rupture of
the repair (especially with host tis-
sue compromise) and the difficulty
of getting satisfactory ligament bal-
ance in both flexion and extension in
severe valgus knees after imbrica-
tion or reconstruction. This results
from the fact that no true isometric
point for the MCL exists throughout
the range of motion.
Advantages of ligament recon-
struction (either autograft or allo-
graft) include decreasing the amount
of implant constraint necessary
(through use of PS or CR devices and
decreasing the stresses transmitted to
fixation interfaces. Disadvantages in-
clude technical difficulty of flexion-
extension ligament balancing, in-
creased surgical time, and, with
autografts, donor site morbidity.
Intraoperative Injury of the
Medial Collateral Ligament
MCL injury may occur intraoper-
atively in a patient with no predis-
522
posing deformity. In one series of
600 consecutive knees with either
varus or neutral alignment that were
treated with primary TKA, 16 knees
(2.7%) sustained an inadvertent in-
traoperative complete MCL inju-
ry.25 The injuries were either mid-
substance disruptions or complete
avulsions of the ligament from bone
during the procedures. Although this
can occur in patients with normal
body mass,25 the incidence of intra-
operative MCL injury appeared far
more frequently in morbidly obese
patients in one report.40
Historically, iatrogenic MCL inju-
ry has been treated using VVC im-
plants, although evidence-based sup-
port for this approach is lacking
because of the relative infrequency
of the complication.3,16,19 Because of
the expected higher rates of aseptic
loosening, the increased resection of
bone required to implant such com-
ponents, and the low likelihood that
VVC components will be available
in the operating room at the time of
what is expected to be an uncompli-
cated TKA,16,25 it seems potentially
advantageous to consider alterna-
tives to this approach, when possi-
ble.
One alternative to increasing im-
plant constraint during a TKA when
a previously normal MCL is injured
intraoperatively is to perform a pri-
mary MCL repair or reattachment
and to protect the repair postopera-
tively with a hinged brace for 6
weeks. In one series, 16 knees were
successfully treated primarily with
reattachment or repair and bracing.
The average Hospital for Special Sur-
gery knee score at a mean follow-up
of 4 years was 93 (excellent). No pa-
tient required bracing beyond the
initial 6-week period, and no patient
demonstrated coronal plane instabil-
ity.25
Complex Instability
It is not possible to anticipate ev-
ery pattern of deformity that may
occur in the context of primary
TKA. For example, in occasional cas-
Journal of the American Academy of Orthopaedic Surgeons
es of coronal plane deformity, partic-
ularly varus deformity, the surgeon
must choose between failing to ob-
tain ligament balance and complete-
ly releasing the tightened medial
structures, thus creating coronal
plane instability. In such cases, sim-
ilar to those of severe valgus previ-
ously described, the surgeon may
have to decide between ligament re-
construction, VVC implants, and, in
the most severe cases of ligament in-
stability, rotating-hinge prostheses.
In addition to patients with se-
vere varus-valgus instability, others
who may benefit from a contempo-
rary design of rotating-hinge knee
are elderly patients with comminut-
ed distal femur fractures or peripros-
thetic fracture nonunion, patients
with extensor-mechanism disrup-
tions and unstable knees, and those
with marked bone loss that cannot
be treated with augmentation or
joint-line adjustments.41,42 Rotating-
hinge knees may have potential
long-term risks, but they offer poten-
tial reconstructive options for pa-
tients with severe, complex instabil-
ity.
Summary
Deciding the amount of constraint to
use in a particular TKA is an impor-
tant, yet challenging, element of pre-
operative planning. Using an implant
with insufficient constraint risks fail-
ure from instability, whereas using a
device that has more constraint than
is necessary can predispose the pa-
tient to aseptic loosening and bone
loss. Clinical factors, such as rheu-
matoid arthritis, prior patellectomy,
severe coronal plane deformity, and
collateral ligament deficiencies or
complex instability, all may influ-
ence the decision regarding the de-
gree of constraint implant to use. For
most primary knees without sub-
stantial deformity or a need for diffi-
cult ligament balancing, either a
posterior-stabilized or a cruciate-
retaining design is appropriate. In ev-
ery case, the least constrained im-

plant that provides satisfactory joint
stability should be chosen; soft-tissue
repair or ligament reconstruction
may help decrease the level of con-
straint implant needed.
Acknowledgment
The authors gratefully acknowledge
the support of Debbie L. Ames,
whose assistance was invaluable in
the preparation of this work.
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524 Journal of the American Academy of Orthopaedic Surgeons