Polyethylene Components in Primary Total Knee Arthroplasty: A Comprehensive Overview of Fixed Bearing Design Options

Abstract

The articular design of a polyethylene insert influences the kinematics and overall function of a total knee arthroplasty (TKA). Standard symmetric posterior-stabilized and cruciate-retaining polyethylene designs have a long track record of high patient satisfaction and longevity in TKA. However, the number and variety of polyethylene inserts and articulations have continued to evolve in an attempt to better replicate native knee kinematics or provide additional constraint. Ultracongruent polyethylene designs have been touted as increasing stability while maintaining the benefits of cruciate-retaining knees. Medial pivot and lateral/dual pivot polyethylene designs were introduced to mimic more normal knee kinematics with regard to femoral rollback. Further, with increasing recognition of knee instability as a cause for persistent symptoms and revision TKA, the utilization of midlevel constraint polyethylene inserts has been increasing, with multiple implant companies offering an insert design with increased constraint for use with a primary femoral component. In this rapidly evolving arena in with a myriad of options available, surgeons should be knowledgeable about the design concepts and their applicable uses for specific patient scenarios. Future research is needed to better understand whether a particular type or design of polyethylene insert and articulation leads to improved patient reported outcomes, improved replication of knee kinematics, and long-term durable implant survivorship.

Keywords

knee arthroplasty - polyethylene design - primary total knee - knee design - polyethylene component

Publication History

Received: 30 September 2020

Accepted: 02 January 2021

Article published online:
22 February 2021

• References

• 1 Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg 2005; 13 (08) 515-524
• 2 Insall JN, Lachiewicz PF, Burstein AH. The posterior stabilized condylar prosthesis: a modification of the total condylar design. Two to four-year clinical experience. J Bone Joint Surg Am 1982; 64 (09) 1317-1323
• 3 American Joint Replacment Registry. Sixth AJRR annual report on hip and knee arthroplasty data. Accessed 2019 at: https://www.aaos.org/registries/registry-program/american-joint-replacement-registry/
• 4 Maruyama S, Yoshiya S, Matsui N, Kuroda R, Kurosaka M. Functional comparison of posterior cruciate-retaining versus posterior stabilized total knee arthroplasty. J Arthroplasty 2004; 19 (03) 349-353
• 5 Kim Y-H, Choi Y, Kwon O-R, Kim J-S. Functional outcome and range of motion of high-flexion posterior cruciate-retaining and high-flexion posterior cruciate-substituting total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am 2009; 91 (04) 753-760
• 6 Chaudhary R, Beaupré LA, Johnston DWC. Knee range of motion during the first two years after use of posterior cruciate-stabilizing or posterior cruciate-retaining total knee prostheses. A randomized clinical trial. J Bone Joint Surg Am 2008; 90 (12) 2579-2586
• 7 Clark CR, Rorabeck CH, MacDonald S, MacDonald D, Swafford J, Cleland D. Posterior-stabilized and cruciate-retaining total knee replacement: a randomized study. Clin Orthop Relat Res 2001; (392) 208-212
• 8 Ng FY, Wong HL, Yau WP, Chiu KY, Tang WM. Comparison of range of motion after standard and high-flexion posterior stabilised total knee replacement. Int Orthop 2008; 32 (06) 795-798
• 9 Kim Y-H, Sohn K-S, Kim J-S. Range of motion of standard and high-flexion posterior stabilized total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am 2005; 87 (07) 1470-1475
• 10 Meneghini RM, Stefl MD, Hodge WA, Banks SA. A cam-post mechanism is no longer necessary in modern primary total knee arthroplasty. J Knee Surg 2019; 32 (08) 710-713
• 11 Hamai S, Okazaki K, Shimoto T, Nakahara H, Higaki H, Iwamoto Y. Continuous sagittal radiological evaluation of stair-climbing in cruciate-retaining and posterior-stabilized total knee arthroplasties using image-matching techniques. J Arthroplasty 2015; 30 (05) 864-869
• 12 Lombardi Jr AV, Berend KR. Posterior cruciate ligament-retaining, posterior stabilized, and varus/valgus posterior stabilized constrained articulations in total knee arthroplasty. Instr Course Lect 2006; 55: 419-427
• 13 Laskin RS, O'Flynn HM. The Insall Award. Total knee replacement with posterior cruciate ligament retention in rheumatoid arthritis. Problems and complications. Clin Orthop Relat Res 1997; (345) 24-28
• 14 Jacobs WCH, Clement DJ, Wymenga AB. Retention versus sacrifice of the posterior cruciate ligament in total knee replacement for treatment of osteoarthritis and rheumatoid arthritis. Cochrane Database Syst Rev 2005; (04) CD004803
• 15 Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ. Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop Relat Res 1998; (356) 39-46
• 16 Yoon J-R, Lee D-H, Ko S-N, Shin Y-S. Proprioception in patients with posterior cruciate ligament tears: a meta-analysis comparison of reconstructed and contralateral normal knees. PLoS One 2017; 12 (09) e0184812
• 17 Vandekerckhove P-JTK, Parys R, Tampere T, Linden P, Van den Daelen L, Verdonk PC. Does cruciate retention primary total knee arthroplasty affect proprioception, strength and clinical outcome?. Knee Surg Sports Traumatol Arthrosc 2015; 23 (06) 1644-1652
• 18 Dennis DA, Komistek RD, Colwell Jr CE. et al. In vivo anteroposterior femorotibial translation of total knee arthroplasty: a multicenter analysis. Clin Orthop Relat Res 1998; 356 (356) 47-57
• 19 Gray HA, Guan S, Young TJ, Dowsey MM, Choong PF, Pandy MG. Comparison of posterior-stabilized, cruciate-retaining, and medial-stabilized knee implant motion during gait. J Orthop Res 2019;2020;
• 20 Dennis DA, Komistek RD, Mahfouz MR, Haas BD, Stiehl JB. Multicenter determination of in vivo kinematics after total knee arthroplasty. Clin Orthop Relat Res 2003; 37-57
• 21 Abdel MP, Morrey ME, Jensen MR, Morrey BF. Increased long-term survival of posterior cruciate-retaining versus posterior cruciate-stabilizing total knee replacements. J Bone Joint Surg Am 2011; 93 (22) 2072-2078
• 22 Vertullo CJ, Lewis PL, Lorimer M, Graves SE. The effect on long-term survivorship of surgeon preference for posterior-stabilized or minimally stabilized total knee replacement: an analysis of 63,416 prostheses from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am 2017; 99 (13) 1129-1139
• 23 Spekenbrink-Spooren A, Van Steenbergen LN, Denissen GAW, Swierstra BA, Poolman RW, Nelissen RGHH. Higher mid-term revision rates of posterior stabilized compared with cruciate retaining total knee arthroplasties: 133,841 cemented arthroplasties for osteoarthritis in the Netherlands in 2007-2016. Acta Orthop 2018; 89 (06) 640-645
• 24 Jiang C, Liu Z, Wang Y, Bian Y, Feng B, Weng X. Posterior cruciate ligament retention versus posterior stabilization for total knee arthroplasty: a meta-analysis. PLoS One 2016; 11 (01) e0147865
• 25 Massin P, Boyer P, Sabourin M. Less femorotibial rotation and AP translation in deep-dished total knee arthroplasty. An intraoperative kinematic study using navigation. Knee Surg Sports Traumatol Arthrosc 2012; 20 (09) 1714-1719
• 26 Lützner J, Firmbach F-P, Lützner C, Dexel J, Kirschner S. Similar stability and range of motion between cruciate-retaining and cruciate-substituting ultracongruent insert total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23 (06) 1638-1643
• 27 Song E-K, Lim H-A, Joo S-D, Kim S-K, Lee K-B, Seon J-K. Total knee arthroplasty using ultra-congruent inserts can provide similar stability and function compared with cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25 (11) 3530-3535
• 28 Peters CL, Mulkey P, Erickson J, Anderson MB, Pelt CE. Comparison of total knee arthroplasty with highly congruent anterior-stabilized bearings versus a cruciate-retaining design. Clin Orthop Relat Res 2014; 472 (01) 175-180
• 29 Scott DF. Prospective randomized comparison of posterior-stabilized versus condylar-stabilized total knee arthroplasty: final report of a five-year study. J Arthroplasty 2018; 33 (05) 1384-1388
• 30 Sur Y-J, Koh I-J, Park S-W, Kim H-J, In Y. Condylar-stabilizing tibial inserts do not restore anteroposterior stability after total knee arthroplasty. J Arthroplasty 2015; 30 (04) 587-591
• 31 Bae J-H, Yoon J-R, Sung J-H, Shin Y-S. Posterior-stabilized inserts are preferable to cruciate-substituting ultracongruent inserts due to more favourable kinematics and stability. Knee Surg Sports Traumatol Arthrosc 2018; 26 (11) 3300-3310
• 32 Kim MS, Koh IJ, Kim CK, Choi KY, Jeon JH, In Y. Comparison of joint perception between posterior-stabilized and ultracongruent total knee arthroplasty in the same patient. J Bone Joint Surg Am 2020; 1-9
• 33 Dennis DA, Mahfouz MR, Komistek RD, Hoff W. In vivo determination of normal and anterior cruciate ligament-deficient knee kinematics. J Biomech 2005; 38 (02) 241-253
• 34 Freeman MAR, Pinskerova V. The movement of the knee studied by magnetic resonance imaging. Clin Orthop Relat Res 2003; (410) 35-43
• 35 Macheras GA, Galanakos SP, Lepetsos P, Anastasopoulos PP, Papadakis SA. A long term clinical outcome of the medial pivot knee arthroplasty system. Knee 2017; 24 (02) 447-453
• 36 Øhrn F-D, Gøthesen Ø, Låstad Lygre SH. et al. Decreased survival of medial pivot designs compared with cruciate-retaining designs in TKA Without Patellar Resurfacing. Clin Orthop Relat Res 2020; 478 (06) 1207-1218
• 37 Omori G, Onda N, Shimura M, Hayashi T, Sato T, Koga Y. The effect of geometry of the tibial polyethylene insert on the tibiofemoral contact kinematics in Advance Medial Pivot total knee arthroplasty. J Orthop Sci 2009; 14 (06) 754-760
• 38 Shimmin A, Martinez-Martos S, Owens J, Iorgulescu AD, Banks S. Fluoroscopic motion study confirming the stability of a medial pivot design total knee arthroplasty. Knee 2015; 22 (06) 522-526
• 39 Samy DA, Wolfstadt JI, Vaidee I, Backstein DJ. A retrospective comparison of a medial pivot and posterior-stabilized total knee arthroplasty with respect to patient-reported and radiographic outcomes. J Arthroplasty 2018; 33 (05) 1379-1383
• 40 Indelli PF, Risitano S, Hall KE, Leonardi E, Migliore E. Effect of polyethylene conformity on total knee arthroplasty early clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2019; 27 (04) 1028-1034
• 41 Koo S, Andriacchi TP. The knee joint center of rotation is predominantly on the lateral side during normal walking. J Biomech 2008; 41 (06) 1269-1273
• 42 Kozanek M, Hosseini A, Liu F. et al. Tibiofemoral kinematics and condylar motion during the stance phase of gait. J Biomech 2009; 42 (12) 1877-1884
• 43 Yamaguchi S, Gamada K, Sasho T, Kato H, Sonoda M, Banks SA. In vivo kinematics of anterior cruciate ligament deficient knees during pivot and squat activities. Clin Biomech (Bristol, Avon) 2009; 24 (01) 71-76
• 44 DJO Surgical® EMPOWR 3D Knee®. Surgical Technique Guide. Accessed 2019 at: https://www.djoglobal.com/products/djo-surgical/empowr-3d-knee
• 45 Sandberg R, Deckard ER, Ziemba-Davis M, Banks SA, Meneghini RM. Dual-pivot bearings improve ambulation and promote increased activity levels in total knee arthroplasty: a match-controlled retrospective study. Knee 2019; 26 (06) 1243-1249
• 46 Wright TM. Joint stability in total knee arthroplasty: what is the target for a stable knee?. J Am Acad Orthop Surg 2017; 25 (February): (Suppl. 01) S25-S28
• 47 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
• 48 Konopka J, Weitzler L, Westrich D, Wright TM, Westrich GH. The effect of constraint on post damage in total knee arthroplasty: posterior stabilized vs posterior stabilized constrained inserts. Arthroplast Today 2017; 4 (02) 200-204
• 49 Crawford DA, Law JI, Lombardi Jr AV, Berend KR. Midlevel constraint without stem extensions in primary total knee arthroplasty provides stability without compromising fixation. J Arthroplasty 2018; 33 (09) 2800-2803
• 50 Zarins B, Rowe CR, Harris BA, Watkins MP. Rotational motion of the knee. Am J Sports Med 1983; 11 (03) 152-156