Satisfactory mid-term outcomes of condylar-constrained knee implants in primary total knee arthroplasty: clinical and radiological follow-up.

BACKGROUND: The purpose of this study was to evaluate (1) the reoperation rates and survivorship for septic and aseptic causes, (2) radiographic outcomes, and (3) clinical outcomes of condylar-constrained knee (CCK) implants used in primary total knee arthroplasty (TKA) with severe coronal deformity and/or intraoperative instability. MATERIALS AND METHODS: A consecutive series of CCK implants in primary TKA was retrospectively evaluated in patients with severe coronal deformities. Forty-nine patients (54 knees) were included with a mean follow-up of 9 years (range 6-12). All patients were treated with a single-design, second-generation CCK implant. The primary diagnosis was osteoarthritis in 36 knees, post-traumatic arthritis in 7 knees, and rheumatoid arthritis in 4 knees. Preoperatively, standing femorotibial alignment was varus in 22 knees and valgus in 20 knees. RESULTS: At a mean follow-up of 9 years, overall survivorship was 93.6%. Two knees (4.3%) required revision for periprosthetic joint infection. One knee (2.1%) required subsequent arthroscopy due to patellar clunk syndrome. At final follow-up, no evidence of loosening or migration of any implant was reported, and the mean Knee Society knee scores improved from 43 to 86 points (p < 0.001). The mean Knee Society function scores improved to 59 points (p < 0.001). The average flexion contracture improved from 7° preoperatively to 2° postoperatively and the average flexion from 98° to 110°. No knees reported varus-valgus instability in flexion or extension. CONCLUSION: CCK implants in primary TKA with major coronal deformities and/or intraoperative instability provide good midterm survivorship, comparable with less constrained implants. In specific cases, CCK implants can be considered a viable option with good clinical and radiographic outcomes. However, a higher degree of constraint should be used cautiously, leaving the first choice to less constrained implants. Level of evidence Therapeutic study, level IV.

Acromioclavicular joint instability: anatomy, biomechanics and evaluation.

Acromioclavicular (AC) joint instability is a common source of pain and disability. The injury is most commonly a result of a direct impact to the AC joint. The AC joint is surrounded by a capsule and has an intra-articular synovium and an articular cartilage interface. An articular disc is usually present in the joint, but this varies in size and shape. The AC joint capsule is quite thin, but has considerable ligamentous support; there are four AC ligaments: superior, inferior, anterior and posterior. The coracoclavicular (CC) ligament complex consists of the conoid and trapezoid ligaments. They insert on the posteromedial and anterolateral region of the undersurface of the distal clavicle, respectively. The coracoid origin of the trapezoid covers the posterior half of the coracoid dorsum; the conoid origin is more posterior on the base of the coracoid. Several biomechanical studies showed that horizontal stability of the AC joint is mediated by the AC ligaments while vertical stability is mediated by the CC ligaments. The radiographic classification of AC joint injuries described by Rockwood includes six types: in type I injuries the AC ligaments are sprained, but the joint is intact; in type II injuries, the AC ligaments are torn, but the CC ligaments are intact; in type III injuries both the AC and the CC ligaments are torn; type IV injuries are characterized by complete dislocation with posterior displacement of the distal clavicle into or through the fascia of the trapezius; type V injuries are characterized by a greater degree of soft tissue damage; type VI injuries are inferior AC joint dislocations into a subacromial or subcoracoid position. The diagnosis of AC joint instability can be based on historical data, physical examination and imaging studies. The cross body adduction stress test has the greatest sensitivity, followed by the AC resisted extension test and the O'Brien test. Proper radiographic evaluation of the AC joint is necessary. The Zanca view is the most accurate view for examining the AC joint. The axial view of the shoulder is important in differentiating a type III AC joint injury from a type IV injury.