CHAPTER 8
The Insall-Burstein® Posterior
Stabilized Condylar Knee Prosthesis
Thomas J. Allardyce, Giles R. Scuderi, and John N. Insall
HISTORY OF DEVELOPMENT
The posterior-stabilized condylar knee prosthesis is one
of the many successful condylar prostheses developed
at the Hospital for Special Surgery.1 It was introduced
as a modification of the total condylar knee prosthesis,
which, with its unmatched durability, has been called
the “gold standard” for total knee arthroplasty
longevity2 (Fig. 8.1). Despite clinical survivorship ex-
ceeding 94% at 15 years, shortcomings with the total
condylar knee exposed the weaknesses of the prosthe-
sis and provided the impetus for design change. In 1978,
the posterior-stabilized condylar knee prosthesis was
first implanted at the Hospital for Special Surgery. The
most recent clinical survivorship studies prove that its
durability has surpassed that of the total condylar knee
prosthesis.3 The posterior-stabilized condylar knee pros-
thesis has since undergone many subtle design changes,
with each modification incorporating the merits and
eliminating the weaknesses of the preceding design.
Although the total condylar prosthesis, which was in-
troduced in 1974, is considered to be the predecessor of
the posterior-stabilized condylar knee prosthesis, the to-
tal condylar knee prosthesis and the posterior-stabilized
condylar knee prosthesis are separate types of arthro-
plasties. The total condylar knee prosthesis is a “poste-
rior cruciate ligament-sacrificing” prosthesis, which al-
lows for a larger proximal tibial cancellous surface area
for tibial component fixation.4 The posterior-stabilized
condylar knee prosthesis is similar to the total condylar
knee prosthesis in that both technically require excision
of both cruciate ligaments for prosthesis implantation;
however, the posterior-stabilized condylar knee pros-
thesis is radically different. It is a “posterior cruciate
ligament-substituting” prosthesis, which has a tibal and
femoral component articulation, that allows for femoral
rollback during knee flexion. This “posterior cruciate
67
ligament-substituting” mechanism makes the posterior-
stabilized condylar knee prosthesis both clinically and
mechanically a better prosthesis choice for patients re-
quiring a total knee arthroplasty. The Insall-Burstein I
was the original posterior-stabilized condylar prosthe-
sis developed at the Hospital for Special Surgery and
was the successor of the total condylar prosthesis (Fig.
8.2). It was introduced as a modification of the total
condylar prosthesis to specifically improve joint stabil-
ity, range of motion, and ability to climb stairs. These
goals were to be achieved with the use of a “posterior
cruciate ligament-substituting mechanism.” A trans-
verse cam on the femoral component articulating with
a central polyethylene post on the tibial component
combined with a change in the center of curvature of
the femoral condyles allowed for femoral rollback dur-
ing flexion to improve motion and knee stability. In the
original reports on the performance of the posterior-
stabilized condylar prosthesis, these goals were indeed
achieved.5 It was thought that the design change that
incorporated more component constraint would lead to
either more lucencies around the components or early
loss of fixation. These negative effects were not seen in
the early reports nor in the long-term follow-up. The
horizontal shear force associated with the cam and post
mechanism actually contributed minimally to the re-
sultant vector force acting on the tibial component in
flexion, most of which is pure axial compression (Fig.
8.4). It was felt that the posterior-stabilized condylar
prosthesis design with the posterior femoral rollback
would tend to decrease quadriceps forces for any given
extension moment that would lead to a lower incidence
of patellar complications. However, it became evident
that patellar complications were increasing with this
new design. There were 10 patellar fractures out the
original 118 total knee arthroplasties performed with the
posterior-stabilized condylar knee prosthesis. Most of
68
Figure 8.1. Total condylar prosthesis
these fractures occurred with the larger patellar buttons
and nearly all were associated with excellent knee func-
tion when treated nonoperatively.5 These fractures have
since been attributed to overstuffing of the
patellofemoral joint and to the increased motion real-
ized by the new design rather than to the femoral roll-
back mechanism of the femoral cam and tibial post.
There was another troublesome clinical occurrence
with the patellofemoral articulation in the new design.
Fibrous tissue tended to accumulate in the quadriceps
tendon just above the patellar button. This fibrous tis-
sue frequently became lodged between the leading edge
A B
Figure 8.2. The (A) Install Burstein I prosthesis and
(B) antero-posterior radiographic appearance.
Section 3. Prosthetic Design
of the femoral intercondylar box and the patellar but-
ton when the knee extended from a flexed position. This
phenomenon has been well described in the original re-
port on the posterior-stabilized condylar prosthesis.5
This condition, treatment, and the outcome have since
been well described and has been coined the “ patellar
clunk” syndrome.6 Different degrees of quadriceps ten-
don irritation have been described with the original
posterior-stabilized condylar knee design.7 As a result,
modifications to the original prosthesis have been made.
In 1982, the leading edge of the femoral box at the dis-
tal end of the trochlear groove was cambered to prevent
this quadriceps irritation.7 In 1983, the trochlear groove
was deepened to inhance the patellofemoral tracking.8
Although this change was minor, it did reduce the inci-
dence of patellofemoral symptoms in patients with the
posterior-stabilized condylar knee prosthesis. In a series
of patients reported by Aglietti,7 the incidence of patel-
lar impingement symptoms was reduced from 25% to
15% after the modifications to the patellofemoral artic-
ulations of the posterior-stabilized condylar knee pros-
thesis were made.
A major change to the posterior-stabilized condylar
knee prosthesis came about in November 1980,8 when
a posterior-stabilized prosthesis with a metal-backed
tibial component was first implanted at the Hospital for
Special Surgery. It was determined that in the revision
setting, the primary mode of failure had been the loos-
ening of the tibial component due to poor cancellous os-
seous support of the tibial tray.9 Frequently the best can-
cellous bone is missing in the proximal tibia after a failed
primary total knee arthroplasty. Therefore, the tibial tray
should be indirectly supported by the cortical shell of
the tibia, because its stiffness increases distally and the
cancellous bone stiffness decreases correspondingly.10
As a result, metal backing was introduced into the tib-
ial component to evenly distribute proximal tibial loads
8. The Install-Burstein® Posterior Stabilized Condylar
to the tibial cortical shell rather than the proximal can-
cellous bed. Even in primary total knee arthroplasty
with an all-polyethylene tibial component, the most fre-
quent cause of failure is tibial loosening.11 In one of the
original series of total condylar knees with an all poly-
ethylene tibia, Hood reported that two of the three fail-
ures that occurred were due to aseptic tibial component
loosening.12 In Stern’s 9- to 12-year follow-up study
posterior-stabilized condylar knee prosthesis with an
all-polyethylene tibial component,13 there were twice as
many aseptic failures on the tibial side as compared to
the femoral side. Additionally, fewer radiographic lu-
cencies have been reported around metal-backed tibial
components compared to all-polyethylene tibial com-
ponents. In Colizza’s 10-year follow-up of posterior-
stabilized condylar knee prosthesis with a metal-backed
tibial component,14 nonprogressive lucencies were re-
ported in only 10% of cases. Contrast this with the 49%
incidence of radiolucencies in Stern’s 9- to 12-year
follow-up of posterior-stabilized condylar knees with an
all-polyethylene tibial component. Unequivocally the
introduction of metal backing into the tibial component
reduced the incidence of radiolucencies around the
prosthesis and aseptic loosening of the tibial component.
In October 1981, the last posterior-stabilized condylar
knee prosthesis with an all-polyethylene tibial compo-
nent was implanted at the Hospital for Special Surgery.
Other significant changes were made to the original
posterior-stabilized condylar knee prosthesis, all with
the intention of improving upon the original design. In
September 1988, the Insall-Burstein II was introduced.15
Modularity of components and more component sizes
were the key issues with the new prosthesis. Stems and
wedges became available to enhance component fixa-
tion, and constrained condylar components became
available to enhance stability. Other changes were in-
corporated, including deepening of the trochlear groove
to facilitate patellar tracking. The radii of curvature of
the femoral condyles and the tibial articular surfaces in
the coronal plane were increased to enhance mediolat-
eral rotation. The tibial polyethylene insert was also sig-
nificantly changed to enhance knee flexion by shorten-
ing the tibial post by 2 mm and translating it posteriorly
2 mm.15
One of the initial goals of the Insall-Burstein I poste-
rior-stabilized condylar knee prosthesis was to improve
upon the stability of the total condylar prosthesis in the
anteroposterior direction. The original Insall-Burstein II
tibial post made the articulation more susceptible to dis-
location by shortening the tibial post. Galinat16 reported
the first two cases of dislocation of the Insall-Burstein
posterior-stabilized condylar prosthesis, both occurring
in patients with a preoperative valgus deformity. Lom-
bardi,15 in a review of over 3000 Insall-Burstein poste-
69
rior-stabilized condylar prosthesis between 1981 and
1991, identified 15 cases of posterior tibial dislocation.
There was a statistically significant higher incidence of
Insall-Burstein II dislocations versus Insall-Burstein I
dislocations. This was attributed to the shortening and
posterior translation of the tibial post with the Insall-
Burstein II. In January 1990, the Insall-Burstein II tibial
polyethylene insert was modified by beveling the ante-
rior margin of the polyethylene to decrease patellar but-
ton impingement. The tibial post was also lengthened by
2 mm and translated anteriorly by 2 mm (Fig. 8.5). This
Insall-Burstein II modified version is known as the “2⫹2”
design, and it remains as the present posterior-stabilized
condylar knee tibial insert. With this design, the cruciate-
substituting mechanism of the femoral cam and the tib-
ial post engages at about 75 degrees of knee flexion. This
articulation causes femoral rollback during flexion, but it
does tend to “ride up” the tibial post with increased knee
flexion. This is thought to predispose the prosthesis to
dislocate with increasing amounts of flexion. In Lom-
bardi’s series of posterior-stabilized condylar knees,15 a
statistically higher average range of motion was docu-
mented in those patients who had dislocated compared
to those who had not dislocated. Extensor mechanism
complications have also been implicated in total knee
arthroplasty instability. Sharkey17 reported that all pa-
tients with a posterior-stabilized condylar knee prosthe-
sis who had dislocated and who had a complete clinical
and radiographic review had a history of a valgus de-
formity and a lateral patellar retinacular release. Most im-
portantly all patients who had dislocated had some form
of extensor mechanism disruption with either a patellar
dislocation, patellar tendon rupture, or fracture. Since this
data was collected on patients operated on between 1985
and 1989, most of these patients probably had Insall-
Burstein I prostheses, as opposed to Lombardi’s series of
knee dislocations for which most of the prostheses were
the original Insall-Burstein II designs. Therefore, surgical,
anatomic, and prosthetic design factors all contribute to
instability with the posterior-stabilized condylar knee
prosthesis.
Knee instability in both the primary total knee
arthroplasty and the revision knee was a major consid-
eration in the development of the constrained condylar
knee prosthesis (Fig. 8.3). The constrained condylar
knee, a more constrained version of the posterior-
stabilized condylar knee prosthesis, was developed in
1987 to provide more constraint in both flexion and ex-
tension.8,18 It descended from an earlier design devel-
oped at the Hospital for Special Surgery, known as the
total condylar III prosthesis (Fig. 8.4). The major differ-
ence between the constrained condylar knee and the to-
tal condylar III prosthesis is stem fixation of the femoral
and tibial components. The femoral and tibial stems in
70
A B
Figure 8.3. Constrained condylar knee
prosthesis
the constrained condylar knee prosthesis are completely
modular and do not require cement fixation. The total
condylar III prosthesis stems are nonmodular and were
designed for supplemental cement fixation. The femoral
intercondylar box and tibial post articulation are iden-
tical in the two prostheses.
The constrained condylar knee prosthesis, in addition
to increasing articulation constraint, also enhances com-
ponent fixation in the presence of bone deficiency in
both primary and revision total knee arthroplasty with
the use of stems, wedges, and augments. The con-
strained condylar knee femoral component has the same
femoral condyle design as the posterior-stabilized
condylar knee prosthesis but it incorporates a deeper in-
tercondylar box to accommodate a higher tibial inter-
condylar post. The constrained condylar knee femoral
intercondylar box and tibial post articulation allow for
0 to 120 degrees of knee flexion, 5 degrees of internal
and external rotation, and 3 degrees of varus and val-
gus freedom in full extension.18 The higher tibial post
prevents knee dislocation in flexion by creating a longer
“jumping distance” for the femoral cam. The increased
constraint with the tibial and femoral components in the
constrained condylar knee system has made it an at-
tractive surgical treatment choice in the revision knee,
but it has also been used in the primary setting.18 Good
Section 3. Prosthetic Design
early results have been reported, but it remains to be
seen whether the increased constraint of the constrained
condylar knee articulation will lead to early loosening
and prosthetic failure in the primary total knee arthro-
plasty.
SHORT-TERM RESULTS
Like most other total knee arthroplasty designs, the
early clinical results with the posterior-stabilized condy-
lar prosthesis were uniformly excellent. The 2- to 4-year
experience in the first 118 patients who had a posterior-
stabilized condylar prosthesis implanted showed 96%
good and excellent results according to the Hospital for
Special Surgery Knee Scoring System.5 Groh19 has re-
ported similar results with the posterior-stabilized
condylar knee. In a review of 137 posterior-stabilized to-
tal knee arthroplasty with an average follow-up of 29
months, there were 98% good and excellent results with
few major complications. However, other designs have
shown similar promising early results, only to have de-
sign flaws exposed with long-term follow-up.20
The posterior-stabilized condylar knee was specifi-
cally designed as a modification of the total condylar
prosthesis to improve stair-climbing ability and range
8. The Install-Burstein® Posterior Stabilized Condylar
Figure 8.4. Total condylar III prosthesis
of motion and to prevent posterior tibial subluxation.
These goals were certainly achieved with the new
“cruciate-substituting” design. Insall reported a signifi-
cant improvement in the range of motion in the poste-
rior-stabilized condylar knee group compared to the to-
tal condylar prosthesis group.5 Fewer than one-quarter
of the patients with the total condylar prosthesis could
climb stairs reciprocally compared to 97% of patients
with the posterior-stabilized condylar prosthesis. These
favorable early results with the posterior-stabilized
condylar knee were seen in patients who were not good
candidates for the total condylar prosthesis implant.
Direct clinical comparison of the total condylar pros-
thesis and the posterior-stabilized condylar prosthesis
patient groups is difficult in these retrospective analy-
ses because of the biases in patient selection. The
posterior-stabilized condylar prosthesis was initially im-
planted in patients who had either severe deformity or
persistent instability with the total condylar prosthesis
with intact collateral ligaments. These were patients
who either required more extensive soft tissue release
or in patients with rheumatoid arthritis where the flex-
ion gap is frequently looser than the extension gap.4
The motion obtained in patients with the posterior-sta-
bilized condylar prosthesis improved from 95 degrees to
115 degrees, whereas those patients with the total condy-
lar prosthesis had only 90 degrees of motion postopera-
tively. This difference in motion was statistically signifi-
cant. Maloney and Schurman21 questioned the increased
motion that was realized with the “cruciate-substituting“
mechanism of the posterior-stabilized condylar knee de-
sign. In their series of 104 arthroplasties including the
posterior-stabilized condylar knee and total condylar
knee, the maximum flexion achieved was similar in both
groups. The posterior-stabilized group actually achieved
more flexion but the preoperative motion was greater in
71
this group. The maximum flexion gained with surgery
actually occurred in the total condylar group, which sup-
ports the widely held theory that postoperative motion
is best predicted by preoperative motion and stiffer knees
paradoxically gain more motion with surgery.
The increased motion and increased stability with the
new “cruciate-substituting” design certainly enhanced
knee function by allowing a greater percentage of pa-
tients to reciprocally negotiate stairs. In the early series,
the motion came at considerable cost to the overall per-
formance of the knee extensor mechanism. It was felt at
the outset that the new design with the “femoral roll-
back” during flexion would effectively lengthen the mo-
ment arm of the extensor mechanism and therefore de-
crease the quadriceps and patellar forces for any given
extension moment. This, in turn, was supposed to lead
to fewer patellar and extensor mechanism complica-
tions, but the early results prove this to be incorrect. In
the short-term follow-up with the posterior-stabilized
condylar knee,5 there was an 11% incidence of major
patellar and extensor mechanism complications, in-
cluding 10 patellar fractures. The early results reported
with the total condylar prosthesis including the total
condylar II prosthesis and the total condylar III pros-
thesis revealed only a 0.8% incidence of major patellar
complications.22 This included only one patellar frac-
ture. Insall22 felt that the increased incidence of patellar
fractures with the posterior-stabilized condylar knee
was not caused by the cruciate-substituting mechanism
of the femoral cam and tibial post but rather to the in-
creased motion realized with the new design. Aglietti7
also felt that the extensor mechanism complications, in-
cluding impingement types of symptoms, were not re-
lated to the femoral rollback but rather to the femoral
component design itself. Because many of the early
patellar fractures occurred in patients with larger patel-
lar buttons, it became apparent that the patellofemoral
joint should not be “overstuffed” with the posterior-
stabilized condylar knee prosthesis. Daluga23 has shown
that an increase in the overall anterior to posterior di-
mensions of the knee by more than 12% was a critically
independent variable that correlated with the need for
knee manipulation after arthroplasty. Other variables
have been demonstrated to correlate well with motion,
and therefore, function of the knee. Figgie24 has shown
in a series of 116 posterior-stabilized condylar knees that
the best functional knee results were associated with
neutral or posterior tibial component position with re-
spect to the center line of the tibia, elevation of the joint
line by no more than 8 mm and patellar height between
10 and 30 mm above the joint line. Patellar height has
also been shown to be directly related to the incidence
of impingement symptoms, including the “patellar
clunk,” with the original Insall-Burstein I posterior-
stabilized condylar knee.7,24 Meticulous surgical tech-
72
nique needs to be followed with the posterior-stabilized
condylar knee in that the joint line is normally elevated
and the patellar height is lowered an average of 12 mm
with the standard bone resection and component inser-
tion.24
One concern with the development of the “cruciate-
substituting” mechanism of the tibial post and femoral
cam was that it would increase the horizontal shear
forces across the tibial component, which may predis-
pose to early tibial component loosening. This was cer-
tainly a potential problem because of the already high
incidence of radiolucencies at the bone-cement interface
around the all-polyethylene tibial component in the to-
tal condylar knee.2 Vector force analysis of the posterior-
stabilized condylar knee tibial post and femoral cam
mechanism shows that the majority of forces across the
tibial component are not shear but are compressive
forces. Short-term follow-up of the total condylar pros-
thesis and the posterior-stabilized condylar knee show
a nearly identical incidence of tibial component radi-
olucencies. The vast majority of lucencies are observed
around the tibial tray, with tibial keel lucencies occur-
ring only rarely. The all-polyethylene tibial component
makes radiographic analysis of bone-cement interfaces
more accurate and precise, which makes clinical com-
parison between the all-polyethylene tibial component
of the total condylar prosthesis and the posterior-
stabilized condylar knee more meaningful. The 5-year
radiographic follow-up of the total condylar knee re-
vealed a 36% incidence of nonprogressive bone-cement
radiolucencies around the tibial component, most of
which occurred around the tibial tray. There was only a
0.8% incidence of tibial component loosening with the
total condylar knee (3 of 354). The 2- to 4-year follow-
up of the posterior-stabilized condylar knee5 with an all-
polyethylene tibial component revealed a very similar
32% incidence of nonprogressive radiolucencies around
the tibial component and an identical 0.8% incidence (1
of 118) of tibial component loosening. Radiographic
evaluation of femoral bone-cement lucencies is more dif-
ficult and imprecise due to component rotation, which
tends to obscure bone-cement interfaces. Femoral loos-
ening with both the total condylar prosthesis and
posterior-stabilized condylar knee, however, is very un-
common.2,5,11,19
The posterior-stabilized condylar knee has clearly
been associated with more patellofemoral complications
than either the cruciate-sacrificing or the cruciate-
retaining knees.2,20,25 Theories have been proposed and
supported with retrospective clinical data; however, the
reason is probably multifactorial.5,6,7,8,24 Despite the un-
forgiving patellofemoral mechanism, it still remains the
prosthesis of choice for patients who have had a previ-
ous patellectomy.25,26 Martin reported better overall
clinical results in posterior-stabilized arthroplasties
Section 3. Prosthetic Design
compared to total condylar arthroplasties in patients
with a history of a prior patellectomy.25 The best results
correlated with the amount of time that had elapsed be-
tween the patellectomy and the total knee arthroplasty.
Paletta and Laskin26 reported similar results. They
found better pain and function scores in their cohort of
posterior-stabilized arthroplasties compared to poste-
rior cruciate ligament-retaining arthroplasties. In their
series, better pain relief was observed in patients who
had a patellectomy for a diagnosis of a fractured patella.
Less predictable results occurred in patients with a his-
tory of patellectomy for chondromalacia and os-
teoarthrosis.
The design of the cruciate-substituting mechanism
of the femoral cam and tibial post in the posterior-
stabilized condylar knee offers several advantages in
the patellectomized patient. Posterior tibial subluxation
and knee recurvatum are prevented with the posterior-
stabilized condylar knee. The predictable rollback in the
posterior-stabilized condylar knee compared to cruciate-
retaining designs27 also functionally lengthens the ex-
tensor mechanism moment arm resulting in increased
torque for a given quadriceps contraction. Extensor lags
have been reported in up to 32% of patellectomized pa-
tients undergoing total knee arthroplasty and pain re-
lief is not as predictable as in primary total knee re-
placement. For these reasons, total knee arthroplasty
with the posterior-stabilized condylar knee in the patel-
lectomized patient should still be considered a salvage
operation.
LONG-TERM RESULTS
One method of determining the long-term outcome of
a prosthesis is survivorship analysis.28,29,30 This pro-
vides a tool to predict the probability of implant success
and also an estimate of time to failure. Survivorship
analysis is based on the assumption that the clinical out-
comes are the same for those patients who are followed
for short and long periods of time and for those who
are lost to follow-up. This may be one of the flaws in
survivorship analysis in that it provides the best-case
scenario because the vast majority of total knee arthro-
plasty procedures are successful. Another important
point in survivorship analysis is the definition of end
points, which usually include loosening, revision
surgery, or planned revision surgery. Therefore, sur-
vivorship analysis usually gives the probability of not
having a total knee arthroplasty failure without giving
any information about the quality of the result. The to-
tal condylar knee prosthesis has the longest available
follow-up, however, the posterior-stabilized condylar
knee is associated with fewer failures in comparative
survivorship studies.
8. The Install-Burstein® Posterior Stabilized Condylar
In a series of posterior-stabilized condylar knees us-
ing an all-polyethylene tibial component, Stern13 re-
ported 94% clinical survival at 13 years. Good and ex-
cellent results were reported in 87% of patients using
the HSS knee score, but 49% of the patients had radi-
olucencies around the tibial component. Even though
there was only a 0.4% failure rate per year, most of the
failures (9 of 14) were due to aseptic loosening and 6 of
the 9 aseptic failures were due to tibial component loos-
ening. In a recent study of the posterior-stabilized
condylar knees using a metal-backed tibial component,
96.4% clinical survivorship at 11 years was reported.14
These statistics are very similar to those reported by
Stern,13 however, with the introduction of metal-backing
to the tibial component, there was only a 10% incidence
of nonprogressive radiolucencies around the tibial com-
ponent. Additionally, none of the 159 knees that were
followed were revised for aseptic tibial loosening.
Osteolysis secondary to polyethylene damage and
wear debris is a known cause of total knee arthroplasty
failure. However, in the long-term follow-up study of
the posterior-stabilized condylar knee with a metal-
backed tibial component, Colizza14 has shown specifi-
cally that this knee design is not prone to polyethylene
wear with only 8 cases of slight polyethylene wear in a
series of 101 knees. There was also no clinical evidence
of knee joint reaction (synovitis or swelling) to wear de-
bris in those 8 cases and only 3 cases of progressive ra-
diolucencies were observed, none of which showed clin-
ical evidence of loosening.
Several papers have looked specifically at the sur-
vivorship analysis of total knee arthroplasty, but only a
few have follow-up equal to or greater than 15
years.3,30,31,32 These papers include either the total
condylar knee or the posterior-stabilized condylar knee
with either a metal-backed or an all-polyethylene tibial
component. Even at 21 years, the estimated clinical sur-
vivorship with the total condylar knee is greater than
90%.3 More impressively, the failure rates with the total
condylar knee successor, the posterior-stabilized condy-
lar knee with a metal-backed tibial component, were cut
in half and a greater than 98% survival has been re-
ported at 16 years.3
The excellent long-term results associated with the
posterior-stabilized condylar knee prosthesis have sur-
passed that of the “gold standard” of total knee arthro-
plasty, the total condylar prosthesis. These impressive
statistics are reflective of thoughtful patient selection
and preoperative planning, meticulous surgical tech-
nique and appropriate postoperative patient manage-
ment. Good and excellent outcomes cannot be guaran-
teed even with the use of the posterior-stabilized
condylar knee prosthesis, however, the best chance at a
good result starts with the appropriate prosthesis selec-
tion. The Insall-Burstein posterior-stabilized condylar
73
knee prosthesis has become the prosthesis of choice with
its unmatched survivorship and is now the benchmark
by which all other prostheses will be compared.33
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3. Font-Rodriguez D, Scuderi G, Insall J. Unpublished data.
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