CHAPTER 9
Constrained Prostheses
Kelly G. Vince
INTRODUCTION
Constrained knee arthroplasties, like life boats, are nice
to have but not to use. The considerable forces on the
knee (and an arthroplasty) are more reliably and
durably dissipated by the ligaments around the joint.
Living and elastic soft tissues are far more suited to the
task than nonresilient, mechanical devices. Mechani-
cally constrained knee prostheses, despite the advan-
tage of easily stabilizing even the difficult knee recon-
struction, are more susceptible to loosening, breakage,
and wear than conventional resurfacing prostheses.
BACKGROUND AND DESIGNS
Constrained implants include linked and nonlinked de-
signs. The former are synonymous with hinges, from the
original Walldius1–6 to the more recent kinematic rotat-
ing hinge7 (Fig. 9.1). Nonlinked constrained devices,
such as the Total Condylar III,8–10 were first introduced
in the 1970s. The additional stability or constraint came
from a tall central post on the tibial component that
rested between the two femoral condyles. These im-
plants resist varus and valgus forces, decreasing as well,
the risk of posterior dislocation of the tibia (Fig. 9.2).
Hinged devices were some of the earliest knee re-
placements available, having been introduced in the
early 1950s. The detailed history of these implants is in-
structive.11 Most were implanted in exceedingly small
numbers. Work on hinged knee prostheses spanned
three decades, until the entire concept was largely
abandoned.
The literature on hinged arthroplasties teaches sev-
eral important lessons:
1. Short-term results must be viewed critically. Most
hinges did reasonably well over the first 2 years.
Later, it seemed everyone wanted to forget about
them.
2. There is always a need for follow-up literature from
institutions and individuals who were not involved
75
in the original design. Despite glowing reports from
the developers of the GUEPAR device,12–14 it was in-
dependent surgeons who identified problems with
the implants.15,16
3. Misguided work may persist for many years before
a bad concept is abandoned. Hinges were introduced
in 1953, and there followed at least three decades of
active development and implantation.
Hinges were gradually abandoned. Hui and Fitzgerald
reported a 23% incidence of major complications in 77
hinged arthroplasties, concluding that “whenever pos-
sible, a moderately constrained replacement arthro-
plasty should be considered.”17 Eventually, hinges were
reserved for revision surgery. Bargar and colleagues
found that the GUEPAR and Herbert prostheses they
had used in difficult reconstructions ultimately failed in
large numbers and did not solve the problems of the re-
vision patient.18 “There is no indication for hinge pros-
thesis in revision surgery,” wrote Insall and Dethmers
in 1982.19 This is sound advice, with general consensus.
There are a very few surgeons, in a very few circum-
stances, who would argue that a linked implant is nec-
essary or appropriate.
CURRENT MODELS
Nonlinked constrained knee prostheses, though me-
chanically more sound, are also used infrequently. Nu-
merous styles are available from a variety of manufac-
turers, all based to a greater or lesser extent on the
original total condylar III. Although this type of con-
strained implant has fared surprisingly well in clinical
studies, they are still susceptible to breakage20 and re-
current instability as a result of cold flow (Fig. 9.3). The
spectrum of designs has been described well and in de-
tail by Lombardi.21
Hinged prostheses are still available. Most are rota-
tionally unconstrained, often allowing amounts of rota-
tion, that clearly exceed the physiologic performance or
requirements of the knee. A knee prosthesis may be con-
76
Figure 9.1. Kinematic Rotating Hinge Knee Prosthesis. Despite
the rotational freedom permitted by the design, this implant
was removed because of painful loosening. Radiograph shows
radiolucent lines.
strained in numerous directions (Table 9.1). Some types
of constraint are employed frequently, to a greater or
lesser degree in the majority of condylar type resur-
facing arthroplasties. Medial lateral translation, for ex-
ample, is inhibited by a central, usually polyethylene
eminence in even the most unconstrained replace-
ments. The need for this was recognized early and has
Figure 9.2. Constrained condylar type implant. The mecha-
nism of a prominent tibial spine, housed tightly in a box, be-
tween the two femoral condyles confers stability to varus and
valgus forces in the absence of solid collateral ligaments.
Section 3. Prosthetic Design
Figure 9.3. (A) Broken TC III tibial spine resulting in clinical
instability. (B) Recurrent instability in a constrained condylar
knee arthroplasty secondary to malalignment of the knee,
overload of the prosthesis and cold flow of the tibial spine.
been incorporated into designs for over two decades.22
Except for the flattest articular geometries, now obso-
lete due to concerns over accelerated polyethylene
wear due to “point loading,” there is usually some
“dishing” of the articular surface from the front to the
back that resists anteroposterior translation. Cruciate-
retaining devices rely more heavily on the posterior
cruciate ligament for this mode of stability and poste-
rior-stabilized implants have a spine and cam mecha-
nism that prevent posterior tibial subluxation in the
flexed position. Most of these resurfacing implants
have excellent long-term results without suffering
loosening as an effect of constraint.
Accordingly, when we assess constraint, neither the
conformity of the articular geometry nor simple mech-
anisms like the posterior-stabilized spine and cam
mechanism are likely to be the source of trouble.
Constraint to varus or valgus stresses is problematic,
however. There is general agreement that this constraint
can lead to loosening. The more “play” in the constraint
(i.e., the less constrained) the less likelihood there is of
loosening, but probably the greater risk of instability
9. Constrained Prostheses
Table 9.1. Modes of constraint in knee arthroplasty prostheses
Direction Type of motion Problem?
Anteroposterior Translation No
Mediolateral Translation No
Varus-valgus Arc Yes
Rotation Arc No
Flexion extension stop Arc Definitely
and breakage of the device.23 Both the constrained
condylar type of implants and the hinges provide this
type of constraint.
Rotational freedom, mentioned earlier, has been in-
cluded in several linked designs with the argument that
this will protect against loosening. True, very tight con-
straint to rotation of the tibia on the femur is unphysi-
ologic and will likely expose the device to undue
stresses with normal activities. Generally speaking, it
would be difficult to argue, based on the published se-
ries of implants or laboratory testing that rotational con-
straint alone is a significant cause of arthroplasty fail-
ure by loosening. This is specifically supported by the
observation that total condylar III type designs, as re-
ported by several independent institutions, have per-
formed well, perhaps surprisingly well, given a rela-
tively high degree of rotational constraint.24 By contrast,
rotating hinges have done far less well, despite complete
rotational freedom.7 What is the most significant me-
chanical difference between these two constrained
devices—one linked and the other unlinked? One rota-
tionally unconstrained, the other with some constraint
to rotation?
The hyperextension stop is the qualitative difference
between constrained condylar implants and rotating
hinges. And, the author suggests, it is the most damag-
ing mode of constraint. With every step of the gait cy-
cle the hyperextension stop may engage. The moment
arm of the knee and the mechanical forces are large. Re-
trieved hinges usually have polyethylene bumpers (that
engage during hyperextension), with severe wear or
breakage. Constrained condylar type devices, by con-
trast, require soft tissue stability from posterior struc-
tures to prevent hyperextension. If the soft tissue struc-
tures are available posteriorly, yet the surgeon depends
on an implant to limit hyperextension, a price will be
paid unnecessarily for stability.
Other situations, such as limb salvage for tumor re-
construction, may create a situation in which virtually all
stabilizing structures have been resected and only the im-
plant can stabilize the joint.25 Clearly these are particu-
larly difficult and fortunately infrequent circumstances.
It can be argued then that the most damaging mode
of constraint may well be the hyperextension stop. Con-
straint should be avoided when possible, and when re-
quired, the minimum amount necessary should be em-
77
ployed. Devices with a hyperextension stop should be
avoided whenever possible.
INDICATIONS
Even the best-constrained designs are required infre-
quently. They should be avoided, when possible, in fa-
vor of good soft tissue technique. The two most com-
mon situations that arise where constraint may be
indicated are:
1. The flexion gap that is much larger than the exten-
sion gap and cannot be equalized
2. Varus-valgus instability due to collateral ligament in-
competence
Consider the first situation in which the flexion and ex-
tension gaps cannot be equalized by the selection of ap-
propriate component sizes and sound soft tissue surgery.
A relatively common scenario in difficult revisions and
in correction of severe fixed flexion contractures during
primary surgery is the flexion gap that gapes widely and
is tremendously bigger than the extension gap. The sur-
geon must ensure, in revision arthroplasty that the size
of femoral component, specifically its anteroposterior di-
mension has been chosen with an attempt to stabilize the
knee in flexion (refer to Chapter 55 in this text on revi-
sion TKR technique) and not simply to fit whatever bone
happens to be left after the failed components are re-
moved. If standard components that are undersized are
implanted, there will be a risk of posterior tibial dislo-
cation. This risk will be heightened if the patient has also
had a patellectomy, because the patella, by augmenting
the mechanical effect of the extensor mechanism, is a but-
tress to posterior dislocation of the tibia. There may be
a need for some constraint in this situation. A posterior-
stabilized implant suffices, if the discrepancy is well un-
der a centimeter, but a constrained condylar type device
will be required for greater disparity in the gaps. Before
opting for a linked implant in this situation the surgeon
may consider adjunctive soft tissue reconstruction. Ad-
ditionally, in this situation, if the extensor mechanism is
tightened with a distal advancement of the vastus me-
dialis, the risk of dislocation will decrease, although flex-
ion may also be reduced. Additionally, there has been
limited application of ligament advancement techniques,
in this case anterior advancement of the femoral attach-
ment of the medial collateral ligament to selectively
tighten the flexion gap. This technique, combined with
a constrained implant, will keep the central tibial spine
between the femoral condyles, which prohibits posterior
dislocation.26
The difficult primary knee arthroplasty may also pose
problems of matching flexion and extension gaps. This
occurs most commonly in the correction of a profound
fixed flexion contracture. Elevation or transection of the
78
posterior capsule often leads to greater increases in the
flexion space than the extension space. This usually can
be remedied with a constrained device, though rarely a
linked device.
Conversely, the flexion extension gap mismatch may
also occur when the extension gap exceeds the dimen-
sions of the flexion gap. This would be a very danger-
ous problem to try and solve with any kind of constraint.
The linked device or hinge can only salvage this situa-
tion with the use of a hyperextension stop. This applies
damaging forces to the joint that will lead to rapid fail-
ure. If indeed this type of implant is used and the knee
remains shortened, an incapacitating extensor lag is also
likely to ensue. The true cause of this mismatch should
be appreciated and corrected. In most cases it is the loss
of distal femoral bone that leads to an excessively large
extension gap. Small amounts can be reconstituted with
distal femoral augments on modular femoral compo-
nents. Larger defects will require structural femoral al-
lografts. This type of mismatch cannot be corrected with
constraint alone. Reconstruction of bone is necessary to
restore collateral ligament and posterior capsular soft
tissue tension. In the rare case in which an overly large
extension gap and the concomitant recurvatum defor-
mity result from neurovascular causes, arthroplasty
may be impossible and arthrodesis is indicated.
Constraint is commonly employed when there has
been some degree of plastic failure in the collateral lig-
aments, most importantly on the medial side. Consider
for a moment the relative importance of the two collat-
eral ligaments. A knee arthroplasty must be aligned with
a valgus tibial femoral angle. This is sometimes de-
scribed as a neutral or slightly valgus mechanical axis,
referring to the line drawn from the center of the femoral
head, through the knee, and then to the ankle. With this
alignment, there is generally tension on the medial col-
lateral ligament with each step, and so the ligament
functions as a tension band. The patient may tolerate
some laxity in the lateral stabilizers reasonably well.
This lesson was demonstrated with the first techniques
for correction of valgus deformity by complete transec-
tion to release the structure on the lateral side.27 These
knees remained stable when reconstructed, if they had
been aligned in valgus. This technique has been super-
seded by more elegant and less severe lateral releases,
because of occasional posterior (not varus) instability.
Accordingly, many knee arthroplasty patients function
well with a healthy and strong medial collateral liga-
ment and compromised lateral structures if the appro-
priate valgus alignment has been achieved.
This is not true for the knee without a good or bal-
anced medial collateral ligament. Such a knee will be
unstable with standing and walking. Constraint is usu-
ally required for severe deficiencies of the medial side,
but must never be considered as an alternate or substi-
tute for the conventional techniques of ligament release.
Section 3. Prosthetic Design
Constraint should only be considered in the knee with
valgus instability after the lateral structures have been
released. Once surgical releases are complete on the lat-
eral side (as an attempt to lengthen the lateral side equal
to the length of the stretched medial ligaments),28 then
the knee should be stabilized with thicker polyethylene
inserts on the tibia. The best indication that the medial
collateral ligament is unsatisfactory will be the obser-
vation that medial instability persists even after pro-
gressively thicker inserts have begun to create a flexion
contracture. After all, the medial collateral ligament is
abnormally long due to years of valgus deformity, and
even though the lateral side has been released and
lengthened, the posterior structures remain intact. The
posterior structures define the limit to which thicker
polyethylene can be expected to help.
Whether a constrained condylar, as opposed to a
hinge, can be employed in the functional absence of a
medial collateral ligament is debated. Some surgeons
argue that a constrained implant cannot hope to stabi-
lize this type of knee. The author would favor ligament
advancements or even the use of prosthetic materials
for ligament reconstruction over a linked constrained
device. We might argue further that the role of all varus-
valgus constraint is to temporarily support the knee, un-
til some soft tissue healing has occurred. The analogy
to fracture fixation devices applies; unless the fracture
heals, the fixation device is doomed to break. Corollary
to knee arthroplasty is that unless some collateral-sta-
bilizing soft tissue heals, no amount of mechanical con-
straint can continue to stabilize the arthroplasty.
TECHNIQUE
The surgical technique for each constrained device will
differ by manufacturer and according to the instruments
that are used. There are, however, some principles that
are useful for implantation of a constrained device.
All constrained devices will require enhanced fixa-
tion, usually in the form of medullary stem extensions.
There is currently no data to recommend uncemented
fixation of the constrained implant.
Intramedullary stem extensions may be used with
one of five basic strategies:
1. Large diameter, tightly fitting “press fit stems”2 (Fig.
9.4)
2. Small diameter, intermediate length stems—“dan-
gling stems”
3. Very long, narrow diameter “three-point fixation”
stems
4. Fully cemented stems of intermediate diameter and
usually intermediate length
5. Curved or offset stems that accommodate the asym-
metry of the femur and tibia, achieving superior fit
without compromising component position (Fig. 9.4).
9. Constrained Prostheses
A B
Most intramedullary stems for knee arthroplasty have
been relatively crude and nonanatomic designs. Unlike
hip arthroplasty femoral stems, which have been scru-
tinized intensely to develop geometries that yield su-
perior fit in the proximal femoral canal, most knee pros-
thesis stems have been straight and cylindrical. The
designs have serious implication for surgical technique.
Because of the destruction that was associated with
fully cemented hinges in the past, surgeons became re-
luctant to cement knee arthroplasty stems. Removal of
the fully cemented stem is difficult. Extrication of all
methacrylate in the event of infection is even more prob-
lematic. Enhanced fixation then, without cement, re-
quired a wide stem. Modularity enables the surgeon to
select the necessary width to engage the medullary
canal. However, problems emerge as the stem begins to
determine component position. Wherever a large diam-
eter stem sits in the tibia or femur, is where the compo-
nent will lie.
Since the early 1980s, there has been general consen-
sus that varus position leads to loosening of knee re-
placements.29 However, with the exception of patellar
tracking and appearance, valgus has not been consid-
ered problematic. Due to the asymmetry of the tibia,
large diameter stems invariably sit in 3 to 4 degrees of
valgus relative to the long axis of the shaft of the tibia.
When combined with the 5 to 7 degrees of valgus cast
into most stemmed femoral components and com-
pounded by potential femoral component position in
additional valgus, some revision knee arthroplasties
have ended up in 10 and more degrees of valgus. Al-
though this was not associated with loosening of condy-
lar type replacements, the mechanics of constrained
79
Figure 9.4. Strategies for stem use to
augment fixation in total knee arthro-
plasty: (A) large diameter, tightly fitting
“press fit stems,” (B) curved or offset
stems that accommodate the asymme-
try of the femur and tibia, achieving su-
perior fit without compromising com-
ponent position.
implants differ distinctly. Revision knee arthroplasty in
patients with poor-quality bone using constrained com-
ponents and uncemented canal filling stem extensions
has led to failures in some cases.30
The so-called “dangling stem” would appear not to
augment fixation, because it is not wedged into the tibia.
The cross section of the tibial medullary canal is trian-
gular however, and the appearance of a conventional ra-
diograph may not reveal to what extent the longer, more
narrow stem is, in fact, wedged into the canal. The great
advantage of not filling the canal maximally is that
alignment is not subservient to fit of the stem or the
geometry of the medullary canal. Alignment is of greater
importance.
The very long, but narrow diameter medullary stem
extension has been described in revision arthroplasties,
using unconstrained and sometimes uncemented re-
placements.31 Very little has been written on the use of
these stems with constrained devices. The advantage of
this strategy is that modularity is not required. The nar-
row diameter stems can be cast as a single unit with the
component with the expectation that the narrow diame-
ter will fit any canal. The fixation advantage derives from
the three-point contact that occurs down the canal.
Cemented stems nonetheless have some appeal. Fixa-
tion is immediate and rigid without compromising the
alignment of the arthroplasty. The results with this ap-
proach have been excellent32 but the difficulty of removal,
if it is ever required, remains the great drawback. Fortu-
nately, the technologies that have been developed for re-
moval of implants and cement in revision hip surgery
lend themselves well to the equally difficult task in the
knee.
80
SUMMARY
The constrained knee prosthesis must be regarded as an
occasionally necessary evil. Some difficult primary and
revision knee surgeries must be reconstructed in the ab-
sence of dependable ligamentous structures. When the
flexion gap sags open and the knee is well balanced in
extension, or when the medial collateral ligament in par-
ticular is not functional, some additional maneuver will
be required to stabilize the joint. Constraint, preferably
nonlinked, whether alone or combined with ligamen-
tous reconstruction is often the answer.
Constrained prostheses differ qualitatively and quan-
titatively. The immediate qualitative difference lies be-
tween the linked (hinged) and unlinked prosthesis. The
hinges undoubtedly fail at a more rapid rate than con-
strained condylar designs. The argument is made here
that this is due in large part to the extension stop inher-
ent in the design. Constraint should never be regarded
as a substitute for classic techniques of ligament releases
to correct deformity and stabilize the knee. Hinges should
not be used where a constrained condylar type device
will suffice. Newer, infrequently used techniques for lig-
ament reconstruction may enable the surgeon to stabilize
the difficult knee without recourse to a hinge and per-
haps without a constrained condylar device either.
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