Abstract
Introduction
Modern implant systems offer a variety of options to address the posterior cruciate ligament (PCL) and afford stability in primary total knee arthroplasty (TKA). One system has three bearing options for cruciate retaining (CR) TKA: standard CR bearing (CR-S) with 3° posterior slope and no posterior lip; CR lipped bearing (CR-L) with no slope and small posterior lip, and deep-dished anterior stabilized bearing (CR-AS) with large anterior build-up to compensates for deficient or lax PCL. We previously reported on 1940 patients (2449 CR-TKA) at early follow-up comparing these three CR bearings and found CR-AS bearings had greater improvement in ROM and lower rate of manipulation despite their use in patients with greater preoperative deformity and lower ROM. The purpose of this study was to review a broader series by a single surgeon-designer with minimum 2-year follow-up to determine if there were differences between bearing types in terms of clinical outcomes and survival.
Methods
From 2003 to 2014, 3348 patients (4500 knees) underwent primary CR-TKA and were available for review with minimum 2-year follow-up. An algorithmic approach to constraint was employed, choosing the least amount necessary to afford stability. Bearings used were 3883 CR-S (86%), 256 CR-L (6%), and 361 CR-AS (8%). CR-S bearings were used in patients with less preoperative tibiofemoral deformity (p=0.0316), less flexion contracture (p<0.0001), and better ROM (p<0.0001), but more mediolateral instability (p<0.0001) than CR-AS bearings.
Results
Mean follow-up overall was 5.7 years (range, 2–14). Overall 106 TKA (2.4%) have been revised (46 fully, 56 partial, 4 unknown). Indications for revision were instability in 40 (all CR-S), 28 infection, 10 aseptic loosening, 8 arthrofibrosis, 7 periprosthetic fracture, 3 extensor related, 2 heterotopic ossification, 3 pain, and 5 other or unknown. Chi-squared analysis showed no difference between bearing groups for overall revision (p=0.1724). However, revision for instability was greater for CR-S (1.0%) versus CR-AS bearings (p=0.0454, Fisher's exact). Frequency of manipulation was no different between bearing groups (p=0.8512). CR-AS patients had greater improvement than CR-S patients in ROM (4.4° versus 1.6°, p=0.0003), and Knee Society pain (39.3 versus 35.9, p=0.0002), clinical (53.5 versus 47.0, p<0.0001), and function (18.9 versus 16.0, p=16.0). CR-L patients had greater improvement than CR-S in pain (38.2, p=0.0367) and clinical score (53.6, p<0.0001).
Discussion
In this large single surgeon series, Kaplan-Meier survival free of any revision was similar between bearing groups and excellent overall with 96.0% (±0.49%) at 14.1 years. No revisions for instability were observed with CR-L or CR-AS bearings, but were the most frequent cause of revision with CR-S bearings. Manipulation rates were similar between bearing groups. ROM, pain, clinical, and functional improvements were greater with a deep-dished, anterior-stabilized bearing.
