The knowledge of the biological and mechanical factors
which have an influnce in non cemented knee
prosthesis' survival and the complexity of the biomechanical
(kinematic) demands to which are summitted
the different non cemented prosthesis, show the importance
of a "natural" solution specially in the field of the
substitition of the interposition fibrocartilague structures,
such as the meniscus. In the same way it is important
to study the behaviourof the different revetment
surfaces (Titanium, chrom-cobalt etc..) Lastly, a solid
fixation of the implant demands a quality bone, that, in
its case, will have come from an autograft

Keblish, Peter A.

Biomecánica

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BIOMECANICA-ORIGINALES Prosthetic fixation in cementless total knee arthoplasty. Influence of techniques, prosthetic design and bone graft enhacement SUMMARY The knowledge of the biological and mechanical fac- tors which have an influnce in non cemented knee prosthesis' survival and the complexity of the biome- chanical (kinematic) demands to which are summitted the different non cemented prosthesis, show the impor- tance of a "natural" solution specially in the field of the substitition of the interposition fibrocartilague structu- res, such as the meniscus. In the same way it is impor- tant to study the behaviourof the different revetment surfaces (Titanium, chrom-cobalt etc..) Lastly, a solid fixation of the implant demands a quality bone, that, in its case, will have come from an autograft. Key words: Non cemented knee prosthesis. Design. Bony graft. RESUMEN El conocimiento de los factores biológicos y mecáni- cos que influyen en la supervivencia de las prótesis de rodilla no cementadas y la complejidad de las exigen- cias biomecánicas (cinemáticas) a las que se someten los diferentes diseños de prótesis no cementadas, indi- can la importancia de una solución «natural» especial- mente en el campo de la sustitución de estructuras fibrocartilaginosas de interposición, tales como el menisco. Asimismo es importante analizar el comporta- miento de diferentes superficies de  revestimento (Titanio y cromocobalto) p. ej.). Por último, una sólida fijación del implante requiere un hueso de calidad, que, en su caso, deberá proceder de autoinjerto. Palabras clave: Prótesis de rodilla no cementada. Diseño. Injerto óseo. INTRODUCTION: THE PROBLEM The knee presents a potential hostile environment for joint replacement, with influences of large mechanical forces, altered kinematics, chemical enzyme release, and artificial (metal/plastic/ceramic) articulating surfa- ces. These factors have been implicated in the most common failure modes in total knee arthroplasty (TKA); namely ultra-high molecular weight polyethyle- ne (UHMWPe) wear, patellar maltracking/loosening, and tibial fixation. Current information suggests that UHMWPe wear particles stimulate the enzymatic casca- de which not influence initial fixation (6 weeks to 6 PETER A. KEBLISH Lehigh Valley Hospital Hanemann University months). In contrast, early fixation failure is due to tech- nique (malalignment), infection, or patellar maltracking. Cementless fixation of the tibial and patellar compo- nents in TKA has become suspect in fixed-bearing designs. Cementless femoral fixation has become accep- ted because of the high success rates in virtually al1 series. Cemented fixation has the advantage of imme- diate fixation, but the known disadvantage of having poor resistance to shearttension forces. Cemented tibiatpatella failures at the bone-metal-plastic interfaces have led to the quest for biologic fixation in order to 1) avoid another material (with inferior properties), 2) allow for osseointegration with the potential for adapti- ve bone remodeling, and 3) provide long-tem fixation. Retrieval analysis (John Collier, PhD., Dartmouth- . Thayer School of Engineering) has shown excellent osseointegration in femoral and patellar components with variable (and lower percentage) integration in tibial components. True osseointegration of retrieved (non- failed) tibial components has been seen in a maximum of 20% to 30% of bone prosthetic interface despite nor- mal clinical function and x-ray appearance. Biologic ingrowth in TKA is technique and design sensitive. Therefore, the success of cementless fixation, especially in the tibia, represents a challenge to the sur- geon and prosthetic designerstengineers. Fixed-bearing TKA design presents a dilemma of high contacta stress (increased wear) or high constrained forces (increased loosening). Incongruent round-on-flat or flat-on-flat designs (point contact) are inherently unstable in antero- posterior (AP), mediolateral (ML) and rotation planes. Flat tibial surfaces allow for relatiely unconstrained motion and are accentuated when the posterior cruciate ligament (PCL) is deficient. The potential for rapid wear and failure becomes a reality when articulating surface mismatch increases the stress beyond the manufacture's limits of materials, such as UHMWPe, (which is appro- ximately twenty megapascales). Highly congruent (fixed-bearing) condylar designs present the opposite efect, namely a translation of higher interface stress to the bone prosthetic interface. Mobility without con- gruency and/or congruency without mobility, therefore, represents a necessary but less than ideal compromise in fixed-bearing design. Modular metal-backed tibial components have beco- me the standard in fixed-bearing design. However, fai- lures due to bearing motion at the non-articulating surfa- PETER A. KEBLISH ce are now of increasing concern, especially with thin polyethylene components. Non-articulating bearing motion can lead to microscopic bearing lift-off with ini- tiation of shear forces that exceed the UHMWPe limit. Catastrophic break-through of the polyethylene as well as fracture of the patellar base plates have been seen in personal and reported series, primarily in the thin (lesst- han 6 mm) and heat pressed point contact devices, such as the Porous Coated Anatomic (PCA). Screw fixation has become a common mode of secu- ring tibia1 base plates. Biomechanical studies support the fact that superior einitial fixationn of the upper tibia is accomplished with the use of screws. However. screws and screw holes have the disadvantage of produ- cing problems of metal fretting, corrosion and «cold flown of UHMWPe. Both of these mechanisms produce wear debris which has ease of access to the screw holes, and can potentially lead to osteolysis, loosenning and failure. An increasing number of these types of failures have been seen, suggesting that screws should be aban- doned as a fixation mode in cementless TKA. T H E  PATELLARIFEMORAL ARTICULATION Patella problems have emerged as the most common sources of failure in TKA. Prosthetic resurfacing is the norm in many countries and centers. Problems with the prosthetic patella are multifactorial and include: 1)  mal- tracking which leads to subluxation/dislocation, 2) fixa- tion which leads to loosening via osteolysis and fractures, 3) polyethylene/metal wear leading to synovitis and poten- tial loosening of al1 components, and 4) composite disso- ciation of modular units leading to mechanical failure. Factors that influence the potencial success or failure of the resurfaced patella include: 1) blood supply (exten- sive releases), 2) bone bed quality (osteopenia), 3) qua- driceps patellar tendon (QPT tracking) mal-alignment, 4) joint line location (technique), 5 )  position (Bqja/Alta), 6 )  fixation (cement/cementless), and 7) design (fixed dome, fixed anatomic, or moveable anatomic). The variation in femoral and patellar component design as well as technique must be evaluated by the operating surgeon. Poor femoral design and subtle mal- alignment problems have lead to a myriad of failures. Selective patellar retention (non-resurfacing) should be considered if risk factors noted above are suspect. Anterior Knee pain and maltracking are the ma.jor risk factors with patellar retention. Biologic adaptation and remodeling of the non-resurfaced patella (figure 1 )  to a reasonably anatomic femoral flange minimizes the many failure modes of the resurfaced patella. Personal experience with patellar resurfacing and non-resurfacing Femoral Groove Geometry Closely Conforms to Patella I 1 Figura 1. B I O M E C A N I C A - O R I G I N A L E S  Figura 2. in the same patient has shown equivalent results utili- zing the low contact stress (LCS) inoveable bearing sys- tem. Results of patellar non-resurfacing in over four hundred TKAs with a mean follow-up of 5.5 years has shown a failure rate of less than one-percent. In addi- tion, patellar retention eliminates problems of fixation and UHMWPe wear. MOVEARLE REARINGS The complexity of Knee biomechanics/kinematics challenges prosthetic knee design. Nature's solution of adaptation to the translational/rotational demandas of knee function are the development of inter-positional f ibro-cart i lage structures we refer to as menisci. Teleologically (adaptación to a definitive function), the knee menisci allow for: 1 )  dynamic movement of the femur on the tibia, 2) adaptation to the complex kinema- tics, 3) increase in articulating surface contact (incon- gruent to optimally congruent), 4) optimum (lower) con- tact stress, and S )  protection of hyaline cartilage. The mechanical analog to menisci, from a prosthetic standpoint, are moveable bearings. This concept was developed by the Oxford Group (Good fellow) with the uni-compartment, and extended by the New Jersey Group (Buechel, Pappas) to a total knee system. The Rotating Platform Figura 3. 48 LCS(N,w Jersey) knee system addresses the dilemma of fixed-bearing design. Articular congruity is provided by «matching» generating curves (in the AP and ML pla- nes). Mobility is provided by allowing meniscal bea- rings to translate in dovetail radial tracks when the PCL is functional, (figure 2), or rotate around a central stem when the PCL is deficient, (figure 3). A rotating anato- mic patellar design (FIgue 4) allows adaptation to the femoral flange, improving patellar-femoral tracking and stability while decreasing contact stresses. Patellar fixa- tion has provern to be predictable in both cemented and cementless multi-center LCS trials, with less than one- percent overall complication rate (2% of which were related to fixation). Fixation and wear are related to con- gruency and stability at the femoral-tibia1 and the pate- llar-femoral articulations. lncongruent design, thin UHMWPe and metallica backed patella components can accentuate minor maltracking and lead to increased, and sometimes rapid, failure in an otherwise well aligned TKA. The surface treatment of cementless devices varies with different prosthesis. Titanium fiber mesh continues to be used, however, cobalt chrome porous coatint with bead sizes between 125-550 micra ( P o r ~ c o a t ( ~ ~  , warsaw, has the longest clinical experience. +he Porocoat processing affords a proud surface, ( 1  -2 mm) which allows for improved implant fixation stability. PETER A. KEBLISH Figura 5. Patella Component Geometry Closely Conforms to Normal Patella Geometry Figura 4. 49 B I O M E C A N I C A - O R I G I N A L E S  The issue of titanium vs. cobalt chrome however, remains debatable. Although titanium provides a satis- factory fixation surface, it is not acceptable as an articu- lating surface without specialized treatment. Cobalt chrome, therefore, remains the so-called gold standard. TECHNIQUEIBONE GRAFT ENHANCEMENT Implant technique varies with different TKA systems. The ultimate goal is mechanical alignment of 4-7 degre- es valgus with AP, ML and patellar-femoral stability. Flexion-extension gap balance is the key to establishing stable mechanical alignment. The «femoral first» resec- tion approach relies on estimation of the distal AP femoral cut and frequently places the femoral compo- nent in an interna1 rotation plane. The «tibia1 first» resection approach, as used in the LCS system, allows for precise distal femoral AP fesection based on balan- ced ligament tension. The rotational position of the dis- tal femoral component influences patellar tracking and the complex kinematics of the femoral tibial articula- tion, especially if the PCL is retained. Interna1 positio- ning of the femoral component, however, should be avoided! ! Biologic (fibro-osseous) integration can occur only if the implant technique is precise and porous coated sur- faces are in contact with host bone or autograft. The tibia presents the challenge since the majority of failures have occurred on the tibial side. The metaphyseal, fully porocoated, tapered cone of the LCS tibial component (figure 5) has proven to be effective from a clinical standpoint. Results from multi-centered trial studies have shown less than one-percent revision for tibial loo- senings (935 cementless knees with 2-8 year follow-up). Radiologic assessment has also shown that interfaces remain stable over time. Bone graft enhancement of primary as well as revi- sion TKA is important in achieving precise interference fit. Osteopenic bone, such as seen in rheumatoid arthri- tis, can be enhanced by the use of cortico-cancellous strut graft (stonehenge technique). Bone slurry or cance- llous autograft can be obtained by multiple drilling or curettement. An excess of bone is available from the femoral condyle, upper tibia and patella (if resurfaced). Autograft in primary TKA is encouraged for both cementless and cemented technique on the tibial side in order to improve the biologic quality, long term fixation and survival. SUMMARY AND CONCLUSIONS Prosthetic fixation in TKA is dependent on many fac- tors. Cementless implantation, primarily on the tibial side, places an added demand on surgical technique and prosthetic design to achieve predictable, long term fixa- tion and success. Congruent articulation with moveable bearings addresses the dilemma of instability and immo- bility present in fixed-bearing T U ,  and decreases UHMWPe wear. Bone graft enhancement and achieve- ment of an interference fit (with proven porous coated surfaces) are required for consistent and predictable suc- cess of cementless fixation, especially on the tibial side. REFERENCES Bert JM. Dislocation/subluxation of meniscal bear in~  elements after New Jersey lowcontact stress total knee arthro$asty. Clin Orthop. 1990; 254:211-215. Buechel FF. Letter to the editor. Clin Orthop. 1991; 264:309- 3 10. Buechel FF. Pappas MJ. New Jersey low contact stress knee replacement system: ten year evaluation of meniscal bearings. Orhop Clin North Am. 1989; 2: 147-177. Buechel FF, Pappas MJ. The New Jersey low contact stress knee replacement system: biomechanical rationales and review of the first 123 cemented cases. Arch Orthop Trauma Surg. 1986; 1 n5.197-7n4 - - . - . - . . Buechel FF, Rosa RA, Pappas MJ. A metal-backed, rotating-bea- ring patellar prosthesis to lower contact stress (an 11 year clinical study). Clin Orthop. 1989; 248:34-49. Goodfellow JW, O'Connor JJ. Clinical results of the Oxford knee: surface arthroplasty of the tibiofemoral joint with a menis- cal bearing prosthesis. Clin Orthop. 1986; 205:21-42. Goodfellow JW, O'Connor JJ. The mechanics of the knee and the prosthetic design. J Bone Joint Surg. 1978; 60B:358-369. Keblish PA. The lateral approach to the valgus knee: surgical technique and analysis of 53 cases over two-year evaluation. Clin Orthop. 1991; 27132-62. Keblish PA, Peoples SJ.  Survivosrship in Total  Knee Replacement. Presented at the 55 th Annual AAOS Meeting; 1988; Atlanta, GA. 

Prosthetic fixation in cementless total knee arthoplasty. Influence of techniques, prosthetic design and bone graft enhacement

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