LeeBeomKoo

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Mobile bearing knee replacement

• LeeBeomKoo

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(No Transcript)
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malrotation of tibia component(15o) self
correction of rotation
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Mobile bearing since 1978
Frederick F. Buechel, MD, FACS
The Journal of Arthroplasty Vol. 19 No. 4 Suppl.
1 June 2004
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(No Transcript)
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Mobile bearing? ?? ?? ??
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CONTACT STRESSES vs GEOMETRY IN TKR
mobile bearing TKA Greenwald P195 ICL'05
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Rapid Failure
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40
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CONTACT STRESS MPa
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Compressive
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Yield Stress
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32 MPa
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Danger
Industrial Limit 10 MPa
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Caution
3.9
Medical Limit 5 MPa
Safe
POINT (Total Condylar)
AREA (LCS) (Rotating Platform)
LINE (PCA)
QUASI-LINE (Whiteside)
2200 N_at_ 15 Flexion
DURING HEEL STRIKE OF GAIT CYCLE
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Translation (posterior-stabilized
rotating-platform knee ) (NexGen LPS Flex Mobile

• The femoral condyle translated posteriorly from
  extension to
• maximum flexion.
• Total posterior condylar
• translations averaged 11.6 and
• 4.7 mm for the lateral and
• medial condyles, respectively.

Pages 164-169JA feb 2008Kenrin Shi, Kenji
Hayashida, Naoya Umeda, Kengo Yamamoto and Hideo
Kawai
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Translation High-Flexion, Posterior-Stabilized,
Mobile-Bearing Knee
LPS-FLEX mobile-bearing knee prosthesis
JA September 2009, Pages 972-978 Masashi Tamaki
MD, Tetsuya Tomita MD, , Tetsu Watanabe MD,
Takaharu Yamazaki PhD, Hideki Yoshikawa MD and
Kazuomi Sugamoto MD
Early and bicondylar roll back
In Vivo Kinematic Analysis of a High-Flexion,
Posterior-Stabilized, Mobile-Bearing Knee
Prosthesis in Deep Knee Bending Motion
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Rotation posterior-stabilized mobile-bearing
prosthesis (NexGen LPS Flex Mobile
Rotation of MB

• Tibial internal rotation in 19 knees averaged 9
  from extension to maximum flexion.

Kenrin Shi, Kenji Hayashida, Naoya Umeda JA feb
2008 Pages 164-169,
Eiichi Nakamura MD, PhD JA October 2009, Pages
1120-1124 , ,
Masashi Tamaki MD, Tetsuya Tomita MD, , JA
September 2009, Pages 972-978
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Rotation of MB

• maximum of 7 internal (tibial rotation) in the
  RP,
• 1.5 times that of the FB, which peaked at
  approximately 4.5 internally.

Hani Haider1 and Kevin Garvin2  CORR nov 2008-
Rotating Platform versus Fixed-bearing Total
Knees An In Vitro Study of Wear
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Polyethylene Wear
Rate
PFC sigma rotating platform mobile-bearing knee
John Fisher DEng, Clin Orthop Relat Res (2010)
4681218
Result of mobile baering TKA JamesB.Stiehl
ICL'05 P233)
Dennis, Douglas A MD CORR 2006 Nov.
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Lift off

• same in fixed and mobile bearing
• incidence 45-100
• ranging 0.78mm-3.53mm
• most commonly observed between 60-90
• pattern
• lateral lift in CR
• both medial and lat lift in PS

(Stiehl 2001 CORR 392 P56)
Kinematic of mobile bearing   Dennis ICL'05 P207
(Otto CORR410'03P181
Buechel The Journal of Arthroplasty Vol. 19 No. 4
Suppl. 1 June 2004
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Buechel The Journal of Arthroplasty Vol. 19 No. 4
Suppl. 1 June 2004
(Buechel CORR404 2002 P40)
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Survival

• LCS survival  95-100/11-12 Yr
• LCS 93/ 5-13 Yr
• Cementless 97 at 17 years

(John Calahan CORR 392 P221)
(Hartford JA Dec'01 P 977)
( Ivan S. Tarkin MD? JA June'05 P481
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Osteolysis After Unidirectional and
Multidirectional Mobile-Bearing Total Knee
Arthroplasty in Young Patients

• Preoperative and postoperative knee and
  functional scores were not different between the
  2 groups.
• No knee in either group had detectable tibial
  polyethylene liner wear or osteolysis on
  radiographs or on computed tomography scans. Two
  (3) knees in each group were revised.

JA june 2009 Pages 586-593Young-Hoo Kim,
Jun-Shik Kim, Yoowang Choi
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FunctionRotaglide mobile knee

• permitted anteroposterior
• translation of 5 mmcomponent of 12.58 on either
  side of the midline
• 7.3 Yr F-up
• The patients demonstrated an excellent knee and
  function International Knee Society Score of 98
  and 93.6, respectively, with an Oxford Knee Score
  of 15.5.
• One knee was revised for traumatic dislocation
  of the mobile bearing. There were no revisions
  for aseptic loosening or deep infection. This
  study demonstrates encouraging midterm results
  for this device in a young patient cohort.
• Pages 525-530JA june'2007
• Mamdouh Morgan, Stuart Brooks and Richard Andrew
  Nelson

Total Knee Arthroplasty in Young Active
Patients mean age,50 Yr Using a Highly Congruent
Fully Mobile Prosthesis
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Pat-fem Cx in LCS

• paucity of pat-fem CX in LCS
• favorable pat resurf in LCS
• factor
•    anatomic shape of femoral groove
•   tibia cut 1st optimizing fem rotation
• highly conforming patella implant

Result of mobile baering TKA JamesB.Stiehl
ICL'05 P233)
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Lateral Retinacular Release Rates in Mobile-
versus Fixed-bearing TKA

• We performed more lateral releases in the
  fixed-bearing group (14.3 54 of 378) than in
  the mobile-bearing group (5.3 50 of 940).
• No patient had patellar subluxation greater than
  5 mm
• We suspect the fewer lateral releases in the
  mobile-bearing group is
• the result of better extensor mechanism
  centralization provided by
• bearing rotation.

posterior-stabilized knee design (PFC1 SigmaTM
DePuy Orthopaedics
Charles C. Yang1, Lee A. McFadden2,
Douglas A. Dennis3, 4, 5, 6  , Raymond H. Kim3
and Adrija Sharma7 CORR Nov 2008-
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clinical result same
Mobile bearing vs fixed bearing

• Woolson JA Feb04 135
• ??? CORR 392 '01 P101
• Iglietti JA Feb'05 P145
• J. Bohannon Mason, JA feb 2008 Page 330
• Kwang Jun Oh JA september 2009, Pages 873-
• Melvyn A. Harrington, JA sept 2009
• Amar S. Ranawat JA 2004 jan Pages 35-39

,
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ROM no difference
Mobile bearing vs fixed bearing

• Woolson JA Feb2004 135
• ??? CORR 392, 2001 P101
• Matthew C. Evans, JA oct'06 P991
• Kwang Jun Oh JA september 2009 P 873
• Melvyn A. Harrington, MD, William J. Hopkinson,
• JA sept 2009 .

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Mobile bearing? ?? ? ? ??
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Diadvantage or Problems of MB
JamesB.Stiehl ICL'05 P233)

• rotating platform dislocation(3.2)

(John Calahan CORR 392 P221)
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Problems of Mobile Bearing
sharp edge itself condylar lift off
edge fracture
Prevalence of Osteolysis After Simultaneous
Bilateral Fixed- and Mobile-Bearing Total Knee
Arthroplasties in Young Patients JASeptember
2009, Pages 932-940
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complication
incidence
( Sansone JA Sep'04)

• Instability2/112
• dislocation of liner 1/112
• meniscal bearing 4.4
• Cx
• dislocation 2
• A-P inst 4
• subluxation 10
• reop rate 10

JamesB.Stiehl ICL'05 P233)
(Bhan JA Dec'03 P1016)
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Bearing complication
Factor

• Flexion extension gap instability
• Malrotation of tibia component
• Late rupture of PCL
• Traumatic twisting

Result of mobile baering TKA JamesB.Stiehl
ICL'05 P233)
(Ridgeway JA sept'04 P686)
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Bearing complication
Symptom period

• Four cases had extensor-mechanism dysfunction.
  Eighteen cases had symptoms immediately
  postoperatively.
• Twenty-three of the 25 cases had symptoms
• within 2 years
• MB?? ??? ????? revision? ??

(Ridgeway JA sept'04 P686)
( Woolson JA Feb04 135
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Polyethylene Wear
gravimetric wear

• rotatingtranslategt rotate onlygt fixed

Rotating platform TKA (Bourne CORR410'03 P173
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Rotating Platform versus Fixed-bearing Total
Knees An In Vitro Study of Wear

• Two of the RP specimens showed infrequent and
  mostly temporary dislocations of the UHMWPE
  insert. The wear rate for the FB averaged
  8.14  2.63 mg/million cycles and the RP averaged
  6.78  1.74 mg/million cycles. Both were very low
  wear rates compared with most other implants
  tested similarly in the same laboratory.
• We concluded polyethylene wear was similar for
  both designs.

Hani Haider1 and Kevin Garvin2  CORR nov 2008-
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Polyethylene Wear
site

• For articular surface wear, there was no
  statistical difference between pitting and
  scratching, but burnishing was twice as much for
  MB inserts (P .003).
• At more than 5 years in situ, the linear wear
  measurements were similar for the 2 groups (mean
  penetration was 0.329 mm for MB and 0.320 mm for
  fixed bearing)

Gerard A. Engh, MD, Rebecca L. Zimmerman, MS,
Nancy L. Parks, MS, and C. Anderson Engh, MD The
Journal of Arthroplasty Vol. 24 No. 6 Suppl. 1
sept 2009
Analysis of Wear in Retrieved Mobile and Fixed
Bearing Knee Inserts
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Polyethylene Wear
backside scores

• For backside scores, there was a minimal amount
  of pitting for both, but the scratching score was
  twice (P .000) and the burnishing score was 3
  times greater for MB inserts (P .000).
• At more than 5 years in situ, the linear wear
  measurements were similar for the 2 groups (mean
  penetration was 0.329 mm for MB and 0.320 mm for
  fixed bearing)

Gerard A. Engh, MD, Rebecca L. Zimmerman, MS,
Nancy L. Parks, MS, and C. Anderson Engh, MD The
Journal of Arthroplasty Vol. 24 No. 6 Suppl. 1
sept 2009
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Polyethylene Wear
site

• Higher levels of superior articulating surface
  damage were found to be associated with higher
  levels of inferior surface damage in this
  retrieval study.

Ryan M. Garcia MD J arthroplasty Jan
2009- Analysis of Retrieved UltraHigh-Molecular-W
eight Polyethylene Tibial Components From
Rotating-Platform Total Knee Arthroplasty
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Polyethylene Wear
factor

• Greater levels of damage were present on both
  surfaces in components with greater radiographic
  radiolucency scores and mechanically loose
  components.
• .

Ryan M. Garcia MD J arthroplasty Jan
2009- Analysis of Retrieved UltraHigh-Molecular-W
eight Polyethylene Tibial Components From
Rotating-Platform Total Knee Arthroplasty
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We have shown that the mobile tibial insert
rapidly reaches its stop at less than 90 flexion.
After this point, the TKA essentially is
transformed into the equivalent of a fixed
bearing implant.
Most E, Li G, Schule S, et al. The kinematics of
fixedand mobile-bearing total knee arthroplasty.
Clin Orthop Relat Res 2003416197.
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RotationLCS rotating platform vs ant gliding
Rotation of MB

• On average, subjects having an LCS RP TKA
  experienced 2.18 of axial rotation from heel
  strike to toe off
• Contrarily, on average, subjects having an APG
• TKA experienced only 0.18 of rotation

(Sugita JA Feb'05P 154)
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Rotation of MB

• .
• Incidences of reverse rotation were observed in
  17 of PS knees, 32 of PCS knees, and 28 of PCR
  knees.
• ..

posterior cruciate sacrificing (PCS)
Axial rotation
PS 4.3
PCS 2.5
PCR 3.8
posterior cruciate retaining PCR
Ray C. Wasielewski1, 2  , Richard D. Komistek3,
Sumesh M. Zingde3, Kate C. Sheridan1 and
Mohamed R. Mahfouz3 CORR Nov 2008
Lack of Axial Rotation in Mobile-bearing Knee
Designs
posterior stabilized (PS),
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Rotation of MB

• Surprisingly, this mobile-bearing prosthesis
  could not cope with tibial tray rotation.
• It required the tibial tray to be neutrally
  aligned to the femoral component to avoid
• excessive polyethylene
• loading.

A Study of the Effect of Tibial Tray Rotation on
a Specific(LCS) Mobile Bearing Total Knee
Arthroplasty
Pages 793-797JA sept'05 Emyr A.H. Chowdhury and
Martyn L. Porter
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Lift off

• We found that increasing tibial tray rotation
• caused excessive polyethylene loading and
• , eventually, medial femoral component liftoff.
• .

A Study of the Effect of Tibial Tray Rotation on
a Specific Mobile Bearing Total Knee Arthroplasty
Pages 793-797JA sept'05 Emyr A.H. Chowdhury and
Martyn L. Porter
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(Otto CORR410'03P181
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Pivot

• pattern
• similar between mobile bearing and fixed
  bearing
• medial pivot 58
• lateral pivot 34
• no pivot 8

Masashi Tamaki MD, Tetsuya Tomita MD, , Tetsu
Watanabe MD JA September 2009, Pages 972-978 ,
Kinematic of mobile bearing   Dennis ICL'05 P207
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Translation Posterior Cruciate
RetainingMobile-Bearing Total Knee Arthroplasty

• paradoxical anterior femoral translation
• more in CR
• even in mobile bearing 60
•   fixed bearing 70

Kinematic of mobile bearing   Dennis ICL'05 P207
(Oakeshott JA Dec'03 P1029)
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TranslationLCS rotating platform vs ant
gliding

• Subjects implanted with a rotating platform (RP)
  MB TKA experienced minimal
• anteroposterior (AP) motion
• .

(Sugita JA Feb'05P 154)
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TranslationLCS rotating platform vs ant
gliding

• Subjects implanted with an anterior glide MB TKA
  experienced femoral translation (AP glide).
• AP glide experienced more variable kinematic
  patterns.

(Sugita JA Feb'05P 154)
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-ROM ( decreased)
Mobile bearing vs fixed bearing

•     decreased

Kinematic of mobile bearing   Dennis ICL'05 P207
The LPS group showed a significantly higher
maximum flexion than the MBK group (112 vs
108).
(Iglietti JA Feb'05 P145)
Meniscal bearing 120 Rotating platform108
Stiehl ICL 2005 P234
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Early failure in cementless mobile TKA

• Patients with cementless mobile-bearing TKA also
  had a significantly lower KSCS (161 versus 184,
  Plt.05), significantly higher incidence of pain
  rated more than mild (23 versus 7, Plt.01)
• and a trend toward less arc of motion (1060
  versus 1150 , Plt.2).

(Barrack JA oct'04 101)
LCS mobile bearing TKA (Hartford JA Dec'01 P 977)
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ARE MOBILE BEARING KNEES WORTH THE PREMIUM?
MOBILE BEARINGKNEES PROVIDE NO EARLY CLINICAL
BENEFIT AT MINIMUM FIVE-YEARFOLLOW-UP

• Results Average age was 65 years, and average
  follow-up was 67 months in both groups
• Average pain score was 44 for RP and 48 for FB
  (P .002).
• Average function scores was 72 for RP and 87 for
  FB (P .0001).
• Average total Knee Society score was 91 for RP
  and 96 for FB (P .03).

J. Bohannon Mason, MD
The Journal of Arthroplasty, Volume 23, Issue 2,
February 2008, Page 330
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• Radiographic evaluation showed a 27 incidence of
  radiolucent lines for the femur and a 31
  incidence of radiolucent lines for the tibia.

LCS mobile bearing TKA (Hartford JA Dec'01 P 977)
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• However, overall survivorship was 76, which was
  primarily because of failures of the metal-backed
  rotating patella.

( Ivan S. Tarkin MD? JA June'05 P481
( Woolson JAFeb04 P 135)
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Patella polyethylene failure in LCS

• These 32 cases had 3 types of failure split
• rupture (7 cases), peripheral wear (21),
• and cantilevering breakage (4), respectively
  75, 64.3, and 100 of which showed subluxation
  and/or tilting of the patellar component on the
  prerevision roentgenograms.
• Misalignment at the joint contact surfaces and
• rotational blockage of the mobile patellar
• component were considered the major causes of
  the failure.
• A design of a flatter metallic button (giving
  larger focal thickness of the polyethylene) and
• a dome-shaped polyethylene (reducing stress
  concentration at the pinnacle) may alleviate the
  failure driving mechanism should subluxation or
  tilting of
• the patellar component take place.

(Huang JA Feb'05 202)
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Rotating platform did not improve patella
tracking

• did not decrease lateral release
• rate

(Sigma Press-Fit Condylar, DePuy, Warsaw, IN)
(Pagnano 2004 CORR428 P221)
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Early clinical outcomes of floating platform
mobile-bearing TKAlongitudinal comparison with
fixed-bearing TKA

• in the FB-PS group, no side preference for the MB
  prosthesis wasobserved, and more patients
  preferred knees implanted with the FB prosthesis
  at 12 and 24 months

Tae Kyun KimKnee Surg Sports Traumatol Arthrosc
(2010) 18879-888
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Summary

• Mobile bearing TKA ? wear???
• ? ? ? ?? ? ???
• ROM ? ? ??
• ??? ? ? ?? fixed bearing??, instability wear?
  ??? ? ? ? ? ? ?? ? ???, ? ? ??? ? ?? ??

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Clinical factor related longevity in mobile
bearing
flex-ext gap balance bearing spin out
alignment IR tibia   tray fx
soft tissue release severe wear
mobile bearing TKA Greenwald P195 ICL'05
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Problem of block method
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Problem of intramedullary guiding
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Thank you for your attention