The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue suppl 3

Scientific Exhibits | October 01, 2007

Posterior-Stabilized Constrained Total Knee Arthroplasty for Complex Primary Cases

Adolph V. LombardiJr., MD; Keith R. Berend, MD; Joseph R. Leith, MD; Gerardo P. Mangino, MD; Joanne B. Adams, BFA

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Biomet, Inc. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Biomet, Inc.). Also, a commercial entity (Biomet, Inc.) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

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J Bone Joint Surg Am, 2007 Oct 01;89(suppl 3):90-102. doi: 10.2106/JBJS.G.00586

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Numerous publications clearly support the conclusion that, overall, total knee arthroplasty is successful. The definitive improvement in quality of life, in combination with the aging of the population, has led to an increasing demand for total knee arthroplasty. While cruciate-retaining and posterior-stabilized devices will perform well for the vast majority of patients presenting as candidates for primary total knee arthroplasty, the orthopaedic surgeon occasionally encounters cases of advanced severity (Figs. 1-A and 1-B)1-4. Complex presentations range from higher degrees of ligamentous incompetency to severe restriction of the range of motion with substantial flexion contracture to posttraumatic arthritis and to post-osteotomy deformity of either the distal part of the femur or the proximal part of the tibia. The challenge confronting the reconstructive surgeon is to obtain a well-balanced flexion-extension gap with balanced collateral ligaments. This is frequently best accomplished with a modular system that offers a continuum of constraint (Fig. 2). Modularity allows intraoperative customization; namely, the use of stems, wedges, and augments. Frequently these difficult primary arthroplasties require the use of posterior-stabilized constrained implants1,5-16.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Numerous publications clearly support the conclusion that, overall, total knee arthroplasty is successful. The definitive improvement in quality of life, in combination with the aging of the population, has led to an increasing demand for total knee arthroplasty. While cruciate-retaining and posterior-stabilized devices will perform well for the vast majority of patients presenting as candidates for primary total knee arthroplasty, the orthopaedic surgeon occasionally encounters cases of advanced severity (Figs. 1-A and 1-B)^1-4. Complex presentations range from higher degrees of ligamentous incompetency to severe restriction of the range of motion with substantial flexion contracture to posttraumatic arthritis and to post-osteotomy deformity of either the distal part of the femur or the proximal part of the tibia. The challenge confronting the reconstructive surgeon is to obtain a well-balanced flexion-extension gap with balanced collateral ligaments. This is frequently best accomplished with a modular system that offers a continuum of constraint (Fig. 2). Modularity allows intraoperative customization; namely, the use of stems, wedges, and augments. Frequently these difficult primary arthroplasties require the use of posterior-stabilized constrained implants^1,5-16.

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Figs. 1-A and 1-B: An increased degree of preoperative severity must be addressed with an increased level of prosthetic constraint. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this artwork.) While minimal deformity may be addressed with posterior-cruciate-retaining devices, moderate deformity requires the use of anterior or posterior-stabilized devices; severe deformity requires constrained condylar devices with different options for stems, augments, and wedges; and salvage scenarios require rotating or rigid-hinge devices. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this artwork.)

We previously reported the early clinical results and failure mechanisms in a large series of 395 patients who had undergone a total of 421 consecutive difficult primary and revision total knee arthroplasties performed with a modular posterior-stabilized constrained device¹². At the time of the review, 102 patients (107 knees) had died; the outcomes in these patients were known, and the deaths were unrelated to the index arthroplasty. The duration of follow-up of the living patients averaged five years. The average Knee Society clinical score improved from 48 of a possible 100 points preoperatively to 79 points at the most recent evaluation, whereas the average range of motion improved from 91° to 101°. Overall survivorship, with partial or complete revision for any reason (septic or aseptic) as the end point, was 89%. Survivorship with aseptic revision as the end point was 94%. Revision due to infection was required in twenty-three knees (5%). Of these infections, nine were recurrent in a group of ninety knees that had undergone reimplantation after removal of the original prosthesis because of infection and fourteen developed in the 331 knees without a previous history of infection. There were twenty-four partial or complete aseptic revisions (6%), with six done because of arthrofibrosis, five done because of aseptic loosening, four related to the extensor mechanism, three done because of instability, three done because of periprosthetic fracture, two done because of soft-tissue impingement, and one related to a malignant tumor.

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Fig. 2: A modular system offering a continuum of constraint affords the surgeon many options with which to treat the full spectrum of deformities encountered and to obtain consistently a well-balanced flexion-extension gap with balanced collateral ligaments. (Printed with permission of Biomet, who supplied the images, and of Joint Implant Surgeons, who compiled the graphic.)

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Fig. 3: Types of primary total knee arthroplasty (TKA), in terms of prosthetic constraint, performed by senior author (AVL) from 1988 through 2006. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this artwork.)

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Fig. 4: Graphic demonstrating the prosthetic requirements to address increasing levels of ligamentous incompetency. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this artwork.)

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Fig. 5: Maxim Posterior-Stabilized Constrained total knee arthroplasty component (Biomet, Warsaw, Indiana). (Printed with permission of Joint Implant Surgeons, which holds the copyright to this image.)

The use of antibiotic-impregnated cement has been shown to significantly reduce the prevalence of deep infection after primary total knee arthroplasty (p = 0.0238)¹⁷. We currently use and recommend the use of antibiotic-impregnated cement for all difficult primary and revision arthroplasties. Because implant fixation and prosthetic stability can be achieved and the extensor mechanism can be managed correctly, substantial improvements in terms of pain relief, function, and the range of motion can be expected with the use of a modular posterior-stabilized constrained knee system. Wear and failure due to the modularity of the prosthesis are not among the common failure mechanisms.

While the need for a varus/valgus constrained condylar device is fairly common in revision total knee arthroplasty, its use in primary arthroplasty is rare (Fig. 3). Constrained condylar prostheses are nonlinked devices that offer substantial varus/valgus constraint by virtue of an enlarged, extended tibial spine that fits within the intercondylar notch of the femoral component. This configuration generally allows a degree or two of varus/valgus laxity and a degree or two of rotation. This is distinctly different from a posterior-stabilized device, which provides no varus/valgus stability and no rotational constraint. A posterior-stabilized constrained articulation, rather than a posterior-stabilized articulation, is selected when the medial or lateral collateral ligament is compromised (Fig. 4).

We conducted a retrospective review of one surgeon's (A.V.L. Jr.) ten-year experience with a single design of modular posterior-stabilized constrained total knee arthroplasty; our purpose was to evaluate its application as a primary procedure and to evaluate the midterm outcomes of treatment of these difficult cases. The device utilized in the current study was the Maxim Posterior-Stabilized Constrained implant (Fig. 5), which is one of three major categories of knee implants within the Maxim Complete Knee System (Biomet Orthopaedics, Warsaw, Indiana). This device has a modular design that allows incorporation of stems of varying degrees of width and length. Augments with which to address deficiency of the distal part of the femur or proximal part of the tibia are also available. Posterior-stabilized and posterior-stabilized constrained polyethylene articulations are available. Selection of the posterior-stabilized rather than the posterior-stabilized constrained implant is based on the final intraoperative assessment of coronal stability in flexion and extension. Of the primary total knee arthroplasties performed by the senior author (A.V.L. Jr.) from 1988 through 2006, a posterior-stabilized constrained-type device was used in only 1.3% of the knees and further constraint—that is, a rotating hinge device—was used in 0.5% (Fig. 3).

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Figs. 6-A through 6-H: Figs. 6-A through 6-H Comparison of the femoral components of the Maxim Posterior-Stabilized Constrained knee implant and the Vanguard Super Stabilized knee implant. Fig. 6-A Anteroposterior view of the Maxim implant. Fig. 6-B Anteroposterior view of the Vanguard implant. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.) Fig. 6-C Distal view of the Maxim implant. Fig. 6-D Distal view of the Vanguard implant. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.) Lateral view of the Maxim implant. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this image.) Lateral view of the Vanguard implant. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this image.) Fig. 6-G Superior view of the Maxim implant. Fig. 6-H Superior view of the Vanguard implant. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.)

While still available for use today, the Maxim System has evolved into the Vanguard Complete Knee System (Biomet) (Figs. 6-A through 6-H). The most important differences in the Vanguard System, compared with the Maxim System, include extension and broadening of the anterior flange to facilitate earlier nonconstrained capture of the patella, 2 mm of lateralization of the trochlear groove, anatomical angulation of the trochlear groove at 6.5° of valgus, a swept-back patellofemoral articulation as a result of a more aggressive anterior chamfer resection, greater extension of the trochlear articulation into the tibiofemoral articulation to minimize patellar crepitation and clunk syndrome, an increase in posterior condylar thickness of 1 mm to provide a greater area of contact with deep flexion, broadening of the posterior aspects of the femoral condyles (also to provide a greater area of contact in deep flexion), a gradual increase in the lengths of the posterior aspects of the femoral condyles proportional to size, variation of intercondylar resection (with the resection narrower for smaller sizes than for larger sizes) to facilitate greater preservation of the medial and lateral femoral condyles, a tighter fit of the tibial spine within the intercondylar space to facilitate a greater degree of stability, and a cam extension to provide greater hop height for increased protection against dislocation. Having successfully used the Maxim Posterior-Stabilized Constrained implant, we have transitioned to the Vanguard Super-Stabilized Knee (SSK) constrained implant.

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Fig. 7: Comparison of the preoperative Hospital for Special Surgery and Knee Society clinical scores with those achieved at the most recent postoperative evaluation. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this artwork.)

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Fig. 8: The failures in the study group, defined as any total knee arthroplasty requiring revision of one or more component parts for any reason. (Printed with permission of Joint Implant Surgeons, which holds the copyright to this artwork.)

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Figs. 9-A, 9-B, 9-C, and 9-D: Anteroposterior (Fig. 9-A) and lateral (Fig. 9-B) radiographs of a seventy-year-old man who presented with posttraumatic arthritis of the right knee. The range of motion was 90°, and a 15° flexion contracture was observed. The patient underwent a primary total knee arthroplasty with cementing of a posterior-stabilized constrained component. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.) Anteroposterior (Fig. 9-C) and lateral (Fig. 9-D) radiographs made thirteen years postoperatively demonstrate well-fixed components in satisfactory position and alignment. The Knee Society clinical score was 99 points. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.)

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Figs. 10-A, 10-B, 10-C, and 10-D: Anteroposterior (Fig. 10-A) and lateral (Fig. 10-B) radiographs of a forty-eight-year-old woman who presented with rheumatoid arthritis of the left knee. She had previously undergone joint replacement of both hips and the contralateral knee. She had a 45° range of motion and a valgus malalignment of >15°. She underwent primary total knee arthroplasty with cementing of a posterior-stabilized constrained component. Anteroposterior (Fig. 10-C) and lateral (Fig. 10-D) radiographs made six years postoperatively demonstrate well-fixed components in good position and alignment. The Knee Society clinical score was 90 points. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.)

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

A retrospective review of difficult primary total knee arthroplasties performed by one surgeon (A.V.L. Jr.) between July 1992 and December 2003 identified fifty-three patients with sixty-one involved knees in which a single modular posterior-stabilized constrained design had been implanted. These cases were associated with complex ligamentous deficiency and severe osseous deformity and represent an extremely small percentage of the primary total knee arthroplasties performed during that time period. All of the operations were performed through a standard median parapatellar incision, and metaphyseal cemented fixation was utilized for all components. Preoperative and postoperative Hospital for Special Surgery (HSS) scores (used until 1997) or Knee Society (KS) scores (used from March 1997) were analyzed, as was the range of motion and the need for subsequent surgical or other procedures.

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Figs. 11-A, 11-B, 11-C, 11-D, and 11-E: Anteroposterior (Fig. 11-A) and lateral (Fig. 11-B) radiographs of a seventy-year-old woman who presented with nonunion of a tibial plateau fracture after open reduction and internal fixation. She had deficiency of the patellofemoral mechanism, valgus malalignment of >15°, and medial-lateral instability of >15°. She underwent a total knee arthroplasty with cementing of a posterior-stabilized constrained component. At four years postoperatively, anteroposterior (Fig. 11-C), lateral (Fig. 11-D), and Merchant (Fig. 11-E) radiographs demonstrated well-fixed components in satisfactory position and alignment. The patient had excellent knee stability. The range of motion of the knee was 125°, and the Knee Society clinical score was 100 points. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.)

There were thirteen male and forty female patients. The presenting diagnosis was osteoarthritis in twenty-seven knees (44%), rheumatoid arthritis in fifteen (25%), posttraumatic arthritis in eight (13%), and a failed open reduction and internal fixation of a fracture in eleven (18%). The average age (and standard deviation) at the time of surgery was 63.8 ± 13.8 years (range, twenty-four to eighty-eight years). The average height was 163 cm (64 in), the average weight was 76 kg (168 lb), and the average body mass index was 29.2 ± 6.4 kg/m² (range, 21.0 to 50.4 kg/m²).

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Figs. 12-A, 12-B, 12-C, and 12-D: Anteroposterior (Fig. 12-A) and lateral (Fig. 12-B) radiographs of a fifty-three-year-old woman who presented with osteoarthritis of the left knee. She had varus malalignment of >10°, a flexion contracture of >20°, and an extensor lag of 10°. She underwent a primary total knee arthroplasty with cementing of a posterior-stabilized constrained component. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.) At 2.5 years postoperatively, anteroposterior (Fig. 12-C) and lateral (Fig. 12-D) radiographs demonstrated well-fixed components in satisfactory position and alignment. The range of motion of the knee was 125°, and the Knee Society clinical score was 100 points. (Printed with permission of Joint Implant Surgeons, which holds the copyright to these images.)

Results

Introduction | Materials and Methods | Results | Discussion | References

At the time of follow-up, sixteen patients (eighteen knees) had died; all of the deaths were unrelated to the total knee arthroplasty, and the outcomes of all of the arthroplasties were known. The duration of follow-up of the surviving patients averaged 5.6 years, with a maximum of 13.4 years. The range of motion improved from an average of 89° preoperatively to an average of 103° at the most recent evaluation. The average HSS score (0 to 100 possible points) improved from 49.6 points preoperatively to 76.7 points postoperatively, the average KS clinical score (0 to 100 possible points) improved from 35 to 86.1 points, and the average KS function score (—20 to 100 possible points) improved from 35.2 to 48.4 points (Fig. 7). Eight knees (13%) required manipulation because of postoperative arthrofibrosis. Revision (of any component part) was performed in seven knees (11%) (Fig. 8). Three revisions (5%) were done (at two, twenty-seven, and seventy-seven months) because of deep infection; two of these revisions consisted of radical débridement and two-stage reimplantation, and one was a fusion. There were four aseptic revisions: two (3%) were done (at twenty-nine and forty-months) because of complications related to the extensor mechanism, one (2%) was done (at ninety-five months) because of instability, and one was done (at twenty months) because of a periprosthetic fracture. The revisions due to the extensor mechanism complications consisted of a patellectomy in one knee and a change of the tibial polyethylene insert in the other. All other revisions included a full exchange of the component. There were no revisions due to aseptic loosening (Figs. 9-A, 9-B, 9-C, 9-D, 10-A, 10-B, 10-C, 10-D, 11-A, 11-B, 11-C, 11-D, 11-E, 12-A, 12-B, 12-C, and 12-D).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Over the last twenty-five years, multiple reports of both poor and excellent outcomes following complex total knee arthroplasty have been published. It appears, on the basis of a review of the literature and the current study, that the possible concerns about the increased constraint and modularity necessary to obtain appropriate stability, adequate fixation, and reestablishment of the joint line are not warranted^14,15. Instead, the more common failure mechanisms and reasons for early failures with this modular constrained design of total knee arthroplasty are infection, problems related to the extensor mechanism, and recurrent instability. No cases of aseptic loosening were identified in this series of difficult primary arthroplasties.

Complex primary total knee arthroplasties with constrained condylar devices have had good results in other series. Sprenger and Doerzbacher, in a study of fifty-four primary total knee arthroplasties with use of the GSB-II (Gschwend-Scheier-Bahler-II) implant (Sulzer Medica), noted ten and eighteen-year cumulative life-table survival rates of 95.7% and 88.1%, with removal of the prosthesis or infection as the end point¹⁸. In a series of forty-four primary total knee arthroplasties done with a constrained condylar device in thirty-seven elderly patients with an average of 17.6° of valgus deformity, Easley et al. reported no failures, loosening, or instability after an average duration of follow-up of 7.8 years⁷. Font-Rodriguez et al. noted a seven-year success rate of 98% after sixty-four primary constrained condylar total knee arthroplasties⁸. In a recent study by Anderson et al., of seventy primary total knee arthroplasties done with constrained condylar implants without stems in sixty-one patients, no radiographic evidence of loosening or wear was seen at an average of 44.5 months postoperatively¹⁹. Lachiewicz and Soileau recently reported that, of fifty-four knees (forty-four patients) treated with a primary total knee arthroplasty with a constrained prosthesis and followed for a mean of nine years, two knees required revision because of aseptic loosening (of the tibial component in one and of the femoral component in the other); the survival rate was 96% at ten years¹¹.

The management of instability and the achievement of a functional range of motion depend on both adequate restoration of the joint line and avoidance of flexion instability or patella baja^1,2,12,20. Patellar instability and complications related to the extensor mechanism can be avoided by ensuring correct rotation of the femoral and tibial implants and by following an algorithm for reconstruction²¹. We have addressed the issue of recurrent instability by using the Vanguard Complete Knee System, which is a direct descendent of the Maxim Complete Knee System. Enhanced stability is afforded by increased tolerances of the tibial spine within the intercondylar housing of the femoral component. This system also addresses patellar issues and extensor mechanism-related complications with several design features, including an extended anterior flange to facilitate early capture of the patella within the trochlear groove, a lateralized trochlear groove, a swept-back femoral component facilitated by a tapered anterior chamfer resection, and an extended trochlear groove.

In this series, septic failure was a major factor affecting the early results of complex primary total knee arthroplasty. With recent reports in the literature suggesting that the use of antibiotic-impregnated cement significantly reduces the prevalence of deep infection following primary total knee arthroplasty (p = 0.0238)¹⁷, we currently use such cement for all difficult primary and revision total knee arthroplasties.

Because implant fixation and prosthetic stability can be achieved and the extensor mechanism can be managed correctly, substantial improvements in terms of pain relief, function, and the range of motion can be expected with use of a modular posterior-stabilized constrained knee system. Wear and failure due to modularity of the prosthesis have not been among the failure mechanisms. ?

References

Introduction | Materials and Methods | Results | Discussion | References

Lombardi 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: 419-27.55419 2006 [PubMed]

Lombardi AV Jr. Soft tissue balancing of the knee — flexion. In: Callaghan JJ, Rosenberg AG, Rubash HE, Simonian PT, Wickiewicz TL, editors. The adult knee. Vol 2. Philadelphia: Lippincott Williams and Wilkins; 2003. p 1223-32.21223 2003

Lombardi AV Jr, Mallory TH, Eberle RW. Constrained knee arthroplasty. In: Scott WN, editor. The knee. Vol 2. St. Louis: Mosby-Year Book; 1994. p 1305-23.21305 1994

Lombardi AV Jr, Mallory TH, Eberle RW. Constrained knee arthroplasty. In: Vince KG, editor. Surgery of the knee. Vol 2. Baltimore: Williams and Wilkins Medical Publishing; 1994. p 1331-49.21331 1994

Berend KR, Lombardi AV, Adams JB. Total knee arthroplasty in patients with greater than 20 degrees flexion contracture. Clin Orthop Relat Res. 2006; 452: 83-7.45283 2006 [PubMed][CrossRef]

Clarke HD, Scuderi GR. Flexion instability in primary total knee replacement. J Knee Surg. 2003;16: 123-8.16123 2003 [PubMed]

Easley ME, Insall JN, Scuderi GR, Bullek DD. Primary constrained condylar knee arthroplasty for the arthritic valgus knee. Clin Orthop Relat Res. 2000;380: 58-64.38058 2000 [PubMed][CrossRef]

Font-Rodriguez DE, Scuderi GR, Insall JN. Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res. 1997;345: 79-86.34579 1997

Hartford JM, Goodman SB, Schurman DJ, Knoblick G. Complex primary and revision total knee arthroplasty using the condylar constrained prosthesis: an average 5-year follow-up. J Arthroplasty. 1998;13: 380-7.13380 1998 [CrossRef]

Lachiewicz PF, Falatyn SP. Clinical and radiographic results of the Total Condylar III and Constrained Condylar total knee arthroplasty. J Arthroplasty. 1996; 11: 916-22.11916 1996 [PubMed][CrossRef]

Lachiewicz PF, Soileau ES. Ten-year survival and clinical results of constrained components in primary total knee arthroplasty. J Arthroplasty. 2006;21: 803-8.21803 2006 [PubMed][CrossRef]

Lombardi AV, Berend KR. The role of implant constraint in revision TKA: striking the balance. Orthopedics. 2006;29: 847-9.29847 2006 [PubMed]

McAuley JP, Engh GA. Constraint in total knee arthroplasty: when and what? J Arthroplasty. 2003;18(3 Suppl 1): 51-4.1851 2003 [PubMed][CrossRef]

Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg. 2005;13: 515-24.13515 2005

Naudie DD, Rorabeck CH. Managing instability in total knee arthroplasty with constrained and linked implants. Instr Course Lect. 2004;53: 207-15.53207 2004 [PubMed]

Sculco TP. The role of constraint in total knee arthroplasty. J Arthroplasty. 2006;21(4 Suppl 1): 54-6.2154 2006 [PubMed][CrossRef]

Chiu FY, Chen CM, Lin CF, Lo WH. Cefuroxime-impregnated cement in primary total knee arthroplasty: a prospective, randomized study of three hundred and forty knees. J Bone Joint Surg Am. 2002;84: 759-62.84759 2002

Sprenger TR, Doerzbacher JF. Long-term follow-up of the GSB II total knee used in primary total knee arthroplasty. J Arthroplasty. 2002;17: 176-83.17176 2002 [PubMed][CrossRef]

Anderson JA, Baldini A, MacDonald JH, Pellicci PM, Sculco TP. Primary constrained condylar knee arthroplasty without stem extensions for the valgus knee. Clin Orthop Relat Res. 2006;442: 199-203.442199 2006 [PubMed][CrossRef]

Chonko DJ, Lombardi AV, Berend KR. Patella baja and total knee arthroplasty (TKA): etiology, diagnosis and management. Surg Technol Int. 2004; 12: 231-8.12231 2004 [PubMed]

Lombardi AV Jr, Mallory TH, Herrington SM. Revision of loose patellar components. In: Scuderi GR, Tria AJ Jr, editors. Surgical techniques in total knee arthroplasty. New York: Springer-Verlag; 2002. p 524-32.524 2002

Topics

knee joint ; range of motion ; knee replacement arthroplasty ; joint prosthesis

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Adolph V. LombardiJr., Keith R. Berend, Joseph R. Leith, Gerardo P. Mangino, Joanne B. Adams; Posterior-Stabilized Constrained Total Knee Arthroplasty for Complex Primary Cases. The Journal of Bone & Joint Surgery. 2007 Oct;89(suppl_3):90-102.

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