Download PDF
J Knee Surg 2021; 34(13): 1382-1387
DOI: 10.1055/s-0041-1735162
Special Focus Section

Ligament Balancing and Constraint in Revision Total Knee Arthroplasty

David A. Crawford
1   Joint Implant Surgeons, Inc, New Albany, Ohio
,
Adolph V. Lombardi Jr.
1   Joint Implant Surgeons, Inc, New Albany, Ohio
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Ligament balancing in revision knee arthroplasty is crucial to the success of the procedure. The medial collateral ligament and lateral ligament complex are the primary ligamentous structures that provide stability. Revisions can be performed with nonconstrained cruciate-retaining, posterior cruciate substituting, or anterior-stabilized/ultracongruent inserts when there are symmetrical flexion/extension gaps and intact collateral ligaments. When the collateral ligaments are insufficient either due to attenuation or incompetence from bone loss, a more constrained knee system is needed. Constrained condylar knees provide increased stability to both varus/valgus and rotation forces with a nonlinked construct. This increased constraint, however, does lead to increased stress at the implant–bone interface which requires more robust metaphyseal fixation. In cases of significant soft tissue disruption, severe flexion/extension gap mismatch or extensor mechanism disruption, a rotating hinge knee is needed to restore stability. Advances in revision implant design have led to improved outcomes and longer survivorship then earlier iterations of these implants. Surgeons should always strive to use the least constraint needed to achieve stability but must have a low threshold to increase constraint when ligament integrity is compromised.

Keywords

knee arthroplasty - revision - constraint - hinge - instability


Publication History

Received: 25 May 2021

Accepted: 22 July 2021

Article published online:
10 September 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 The 2020 Annual Report of the American Joint Replacement Registry. Accessed January 18, 2021 at: http://www.aaos.org/registries/publications/ajrr-annual-report/
    PubMedGoogle Scholar
  • 2 Australian Orthopaedic Association National Joint Replacement Registry. Annual Report 2020. Accessed January 10, 2021 at: http://aoanjrr.sahmri.com/annual-reports-2020
    PubMedGoogle Scholar
  • 3 Schwartz AM, Farley KX, Guild GN, Bradbury Jr TL. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030. J Arthroplasty 2020; 35 (6S): S79-S85
    CrossrefPubMedGoogle Scholar
  • 4 Delanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA. Current epidemiology of revision total knee arthroplasty in the United States. J Arthroplasty 2017; 32 (09) 2663-2668
    CrossrefPubMedGoogle Scholar
  • 5 Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall Award paper. Why are total knee arthroplasties failing today?. Clin Orthop Relat Res 2002; (404) 7-13
    CrossrefPubMedGoogle Scholar
  • 6 Wilson CJ, Theodoulou A, Damarell RA, Krishnan J. Knee instability as the primary cause of failure following total knee arthroplasty (TKA): a systematic review on the patient, surgical and implant characteristics of revised TKA patients. Knee 2017; 24 (06) 1271-1281
    CrossrefPubMedGoogle Scholar
  • 7 Postler A, Lützner C, Beyer F, Tille E, Lützner J. Analysis of total knee arthroplasty revision causes. BMC Musculoskelet Disord 2018; 19 (01) 55-61
    CrossrefPubMedGoogle Scholar
  • 8 Ong KL, Lau E, Suggs J, Kurtz SM, Manley MT. Risk of subsequent revision after primary and revision total joint arthroplasty. Clin Orthop Relat Res 2010; 468 (11) 3070-3076
    CrossrefPubMedGoogle Scholar
  • 9 Sakane M, Livesay GA, Fox RJ, Rudy TW, Runco TJ, Woo SLY. Relative contribution of the ACL, MCL, and bony contact to the anterior stability of the knee. Knee Surg Sports Traumatol Arthrosc 1999; 7 (02) 93-97
    CrossrefPubMedGoogle Scholar
  • 10 Robinson JR, Bull AMJ, Thomas RRD, Amis AA. The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity. Am J Sports Med 2006; 34 (11) 1815-1823
    CrossrefPubMedGoogle Scholar
  • 11 Whiteside LA. Soft tissue balancing: the knee. J Arthroplasty 2002; 17 (4, suppl 1): 23-27
    CrossrefPubMedGoogle Scholar
  • 12 Nelson CL, Gioe TJ, Cheng EY, Thompson Jr RC. Implant selection in revision total knee arthroplasty. J Bone Joint Surg Am 2003; 85-A (Suppl. 01) S43-S51
    CrossrefPubMedGoogle Scholar
  • 13 Rawlinson JJ, Peters LE, Campbell DA, Windsor R, Wright TM, Bartel DL. Cancellous bone strains indicate efficacy of stem augmentation in constrained condylar knees. Clin Orthop Relat Res 2005; 440 (440) 107-116
    CrossrefPubMedGoogle Scholar
  • 14 Geary MB, Macknet DM, Ransone MP, Odum SD, Springer BD. Why do revision total knee arthroplasties fail? A single-center review of 1632 revision total knees comparing historic and modern cohorts. J Arthroplasty 2020; 35 (10) 2938-2943
    CrossrefPubMedGoogle Scholar
  • 15 Mulhall KJ, Ghomrawi HM, Scully S, Callaghan JJ, Saleh KJ. Current etiologies and modes of failure in total knee arthroplasty revision. Clin Orthop Relat Res 2006; 446 (446) 45-50
    CrossrefPubMedGoogle Scholar
  • 16 Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P. Tibiofemoral instability in primary total knee replacement: a review, part 1: basic principles and classification. Knee 2005; 12 (04) 257-266
    CrossrefPubMedGoogle Scholar
  • 17 Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P. Tibiofemoral instability in primary total knee replacement: a review part 2: diagnosis, patient evaluation, and treatment. Knee 2005; 12 (05) 336-340
    CrossrefPubMedGoogle Scholar
  • 18 Rodriguez-Merchan EC. Instability following total knee arthroplasty. HSS J 2011; 7 (03) 273-278
    CrossrefPubMedGoogle Scholar
  • 19 Parratte S, Pagnano MW. Instability after total knee arthroplasty. J Bone Joint Surg Am 2008; 90 (01) 184-194
    PubMedGoogle Scholar
  • 20 Whiteside LA. Ligament balancing in revision total knee arthroplasty. Clin Orthop Relat Res 2004; (423) 178-185
    CrossrefPubMedGoogle Scholar
  • 21 Lombardi Jr AV, Berend KR. The role of implant constraint in revision TKA: striking the balance. Orthopedics 2006; 29 (09) 847-849
    CrossrefPubMedGoogle Scholar
  • 22 Fehring TK, Baird III R, Park B, Della Valle C. When polyethylene exchange is appropriate for prosthetic knee instability. J Am Acad Orthop Surg Glob Res Rev 2019; 3 (05) e031
    PubMedGoogle Scholar
  • 23 Baker RP, Masri BA, Greidanus NV, Garbuz DS. Outcome after isolated polyethylene tibial insert exchange in revision total knee arthroplasty. J Arthroplasty 2013; 28 (01) 1-6
    CrossrefPubMedGoogle Scholar
  • 24 Greenwell PH, Shield WP, Chapman DM, Dalury DF. Isolated revision of the polyethylene component at revision total knee arthroplasty has excellent survivorship at ten years. Bone Joint J 2019; 101-B (7_Supple_C): 104-107
    CrossrefPubMedGoogle Scholar
  • 25 Duensing I, Pelt CE, Anderson MB, Erickson J, Gililland J, Peters CL. Revisiting the role of isolated polyethylene exchange for aseptic failures in total knee arthroplasty. Knee 2020; 27 (03) 958-962
    CrossrefPubMedGoogle Scholar
  • 26 Green CC, Haidukewych GJ. Isolated polyethylene insert exchange for flexion instability after primary total knee arthroplasty demonstrated excellent results in properly selected patients. J Arthroplasty 2020; 35 (05) 1328-1332
    CrossrefPubMedGoogle Scholar
  • 27 Laskin RS, Ohnsorge J. The use of standard posterior stabilized implants in revision total knee arthroplasty. Clin Orthop Relat Res 2005; 440 (440) 122-125
    CrossrefPubMedGoogle Scholar
  • 28 Kunze KN, Akram F, Fuller BC, Choi J, Sporer SM, Levine BR. Superior survivorship for posterior stabilized versus constrained condylar articulations after revision total knee arthroplasty: a retrospective, comparative analysis at short-term follow-up. J Arthroplasty 2019; 34 (12) 3012-3017.e1
    CrossrefPubMedGoogle Scholar
  • 29 Moussa ME, Lee YY, Westrich GH, Mehta N, Lyman S, Marx RG. Comparison of revision rates of non-modular constrained versus posterior stabilized total knee arthroplasty: a propensity score matched cohort study. HSS J 2017; 13 (01) 61-65
    CrossrefPubMedGoogle Scholar
  • 30 Pianigiani S, Scheys L, Labey L, Pascale W, Innocenti B. Biomechanical analysis of the post-cam mechanism in a TKA: comparison between conventional and semi-constrained insert designs. Int Biomech 2015; 2: 22
    CrossrefPubMedGoogle Scholar
  • 31 Athwal KK, Willinger L, Manning W, Deehan D, Amis AA. A constrained-condylar fixed-bearing total knee arthroplasty is stabilised by the medial soft tissues. Knee Surg Sports Traumatol Arthrosc 2021; 29 (02) 659-667
    CrossrefPubMedGoogle Scholar
  • 32 Samiezadeh S, Bougherara H, Abolghasemian M, D'Lima D, Backstein D. Rotating hinge knee causes lower bone-implant interface stress compared to constrained condylar knee replacement. Knee Surg Sports Traumatol Arthrosc 2019; 27 (04) 1224-1231
    CrossrefPubMedGoogle Scholar
  • 33 Andreani L, Pianigiani S, Bori E, Lisanti M, Innocenti B. Analysis of biomechanical differences between condylar constrained knee and rotating hinged implants: a numerical study. J Arthroplasty 2020; 35 (01) 278-284
    CrossrefPubMedGoogle Scholar
  • 34 Passias BJ, Adams JB, Lombardi Jr AV, Berend KR, Crawford DA. Long-term outcomes of a modular system in revision total knee arthroplasty. Surg Technol Int 2020; 37: 259-264
    PubMedGoogle Scholar
  • 35 Kolich MT, Adams JB, Morris MJ. et al. Mid-term clinical outcomes and survivorship of a second-generation modular revision knee system. Surg Technol Int 2021; 38: x
    PubMedGoogle Scholar
  • 36 Kim YH, Kim JS. Revision total knee arthroplasty with use of a constrained condylar knee prosthesis. J Bone Joint Surg Am 2009; 91 (06) 1440-1447
    CrossrefPubMedGoogle Scholar
  • 37 Deburge A. ,Guepar. Guepar hinge prosthesis: complications and results with two years' follow-up. Clin Orthop Relat Res 1976; (120) 47-53
    PubMedGoogle Scholar
  • 38 Aubriot JH, Deburge A, Genet JP. GUEPAR Group. GUEPAR hinge knee prosthesis. Orthop Traumatol Surg Res 2014; 100 (01) 27-32
    CrossrefPubMedGoogle Scholar
  • 39 Barrack RL, Lyons TR, Ingraham RQ, Johnson JC. The use of a modular rotating hinge component in salvage revision total knee arthroplasty. J Arthroplasty 2000; 15 (07) 858-866
    CrossrefPubMedGoogle Scholar
  • 40 Neumann DR, Hofstaedter T, Dorn U. Follow-up of a modular rotating hinge knee system in salvage revision total knee arthroplasty. J Arthroplasty 2012; 27 (05) 814-819
    CrossrefPubMedGoogle Scholar
  • 41 Levent A, Suero EM, Gehrke T, Bakhtiari IG, Citak M. Risk factors for aseptic loosening in complex revision total knee arthroplasty using rotating hinge implants. Int Orthop 2021; 45 (01) 125-132
    CrossrefPubMedGoogle Scholar
  • 42 Hermans K, Vandenneucker H, Truijen J, Oosterbosch J, Bellemans J. Hinged versus CCK revision arthroplasty for the stiff total knee. Knee 2019; 26 (01) 222-227
    CrossrefPubMedGoogle Scholar
  • 43 Wignadasan W, Chang JS, Kayani B, Kontoghiorghe C, Haddad FS. Long-term results of revision total knee arthroplasty using a rotating hinge implant. Knee 2021; 28: 72-80
    CrossrefPubMedGoogle Scholar
  • 44 Bingham JS, Bukowski BR, Wyles CC, Pareek A, Berry DJ, Abdel MP. Rotating-hinge revision total knee arthroplasty for treatment of severe arthrofibrosis. J Arthroplasty 2019; 34 (7S): S271-S276
    CrossrefPubMedGoogle Scholar
  • 45 Cottino U, Abdel MP, Perry KI, Mara KC, Lewallen DG, Hanssen AD. Long-term results after total knee arthroplasty with contemporary rotating-hinge prostheses. J Bone Joint Surg Am 2017; 99 (04) 324-330
    CrossrefPubMedGoogle Scholar