The Knee 10(2003) 167–171

0968-0160/03/$ - see front matter� 2002 Elsevier Science B.V. All rights reserved.PII: S0968-0160Ž02.00107-2

Five year review of the Rotaglide total knee Arthroplasty

C.J. Wilson*, B. Fitzgerald, G.R. Tait

Department of Orthopaedic Surgery, Crosshouse Hospital, Kilmarnock KA2 0BE, Scotland, UK

Received 9 May 2002; received in revised form 5 August 2002; accepted 18 September 2002

Abstract

In this study we present the outcome for patients with the Rotaglide mobile meniscal knee prosthesis implanted for osteoarthritis.All patients reviewed had this prosthesis implanted as a primary total knee Arthroplasty in Crosshouse Hospital. The minimumfollow-up period was 5 years(range 5–8.2). Patients were assessed clinically by the junior author(C.W.) and results werestandardised using the Hospital for Specialist Surgery(HSS) knee score. Standard radiographs were taken in antero-posterior andlateral planes to assess for loosening using the Knee Society roentgenographic system. Case notes were then examined forevidence of peri and post-operative problems. Sixty-seven patients(71 knees) were reviewed. Ninety-four percent of patients hadan excellent clinical outcome with HSS scores of 85 or more. Two knees were revised, one for meniscal fracture and one formeniscal dislocation. Both of these failures were early in our series and in a total of 312 knees to date there have been no othermeniscal failures. No knees were revised for aseptic loosening and there have been no deep infections. We feel this prosthesisoffers a safe and effective treatment for osteoarthritis with a good clinical outcome at 5 years with a low level of complications.� 2002 Elsevier Science B.V. All rights reserved.

Keywords: Knee; Arthroplasty; Mobile; Rotaglide; Outcomes

1. Introduction

The Rotaglide total knee Arthroplasty(Corin Medi-cal) has been implanted in our centre for 8 years. Thisthree-part mobile meniscus prosthesis allows the poly-ethylene meniscal component to move in two planes.Antero-posterior(AP) translation of 5 mm is allowedcombined with rotation 12.58 on either side of themidline. Two metal pegs on the tibial tray preventexcessive movement of the meniscal component. Thecondyles of the femoral component are based on thesurface of a sphere. This increases the contact areabetween the femoral component and the meniscal insertthroughout flexion w1,2x. Increased congruity mayreduce production of polyethylene wear debris andtherefore reduce aseptic loosening of the cementedcomponentsw3x. The inferior surface of the meniscalinsert and articulating surface of the tibial baseplate areflat and therefore highly congruent. Movement between

*Corresponding author. Flat 5, 17 Crown Terrace, Glasgow G129ES, Scotland, UK. Tel.:q44-141-339-6816; fax:q44-123-671-3134.

E-mail address: chriswilson42@hotmail.com(C.J. Wilson).

these components may reduce stress at the cementyboneinterfacew4x.

This implant has been used by other centres in theUK, but few results have been published yet concerningits performancew5–7x. In this study we describe theclinical and radiological results of the Rotaglide kneereplacement with a minimum follow-up period of 5years.

2. Method

The case notes for all patients who had RotaglideKnee Replacement implanted in our centre over the last8 years were reviewed. All knees were implanted bytwo senior surgeons in our centre or under their super-vision. A midline incision was used and medial Para-patellar approach. The posterior cruciate ligament waspreserved routinely and components were fixed usingpalacos cement with Gentamycin. All patients implantedby one surgeon(B.F.) underwent patellar resurfacingwhile the other patients did not. The decision to resur-face the patella was on the basis of the surgeon’spreference in this series.

168 C.J. Wilson et al. / The Knee 10 (2003) 167–171

Table 1Relative indications for total knee Arthroplasty

Diagnosis Incidence Percentage

Osteoarthritis 60 89.5Rheumatoid arthritis 6 9.0Post-tibial plateau fracture 1 1.5

Table 2Relative incidences of formal clinical and radiological examination

Incidence Percentage

Total knees 71 100Clinical evaluation 71 100X-ray evaluation 68 95.7

Table 3Incidence of complications of the Rotaglide TKR expressed as apercentage

Complication Incidence Percentage

Dislocated meniscal insert 1 1.4Fractured meniscus 1 1.4Superficial wound infection 2 2.8Deep venous thrombosis 2 2.8Pulmonary embolism 1 1.4Proximal tibial fracture 1 1.4

Total 8 11.2

Patients implanted for at least 5 years were theninvited to attend a review clinic for assessment. Thosewho did not attend were telephoned and offered a furtherappointment. A clinical examination was performed onall patients by the junior author(C.W.) and results werethen standardised using the Hospital for Specialist Sur-gery (HSS) knee scorew8x. Patients were asked to fillout a questionnaire relating to functional status, prob-lems with pain and overall satisfaction. Case notes wereanalysed and a record made of surgical details, implantsused complications and further operative proceduresespecially for implant failure or infection. Informationfrom the data sheets obtained was then entered into anE-Sakura computer database to facilitate further dataanalysis. The indications for TKR are outlined in Table1.

Standardised radiographs were taken of all patientswho attended. Views were taken in the AP and lateralplanes and assessed for evidence of loosening. Theresults were recorded using the Knee Society roentgen-ographic evaluation systemw9x. The apparent thicknessof lucent lines was measured and recorded in millime-tres. Previous films were then reviewed for any evidenceof progressive loosening. The clinical results for patientswith lucent lines were then compared with those inpatients with no lucency to determine if there was asignificant association with a poorer clinical outcome.

3. Results

Case records were evaluated for 74 patients. Fourpatients had died of unrelated causes and 3 were lost tofollow-up. Sixty-seven patients(71 knees) were con-tacted and all attended for clinical review. No patientswere assessed by telephone interview(Table 2). Theminimum follow-up period was 5 years with a range of5–8.2 years. The average age of patients at review was74 years(range 42–91 years). Forty-five knees(63.4%)were implanted in female patients and 28 in males(36.3%) producing an approximate female to male ratioof 2:1. The average HSS knee score was 90.9(range78–98). Forty-six patients had resurfacing of the patellawith an HSS score of 90.93. Twenty-five patients didnot undergo patellar resurfacing and this group werefunctioning well with a HSS score of 90.96. There isno statistical difference between these two groups. No

patients have required re-operation to date for patellarresurfacing.

Two patients required revision one for a dislocatedmeniscal insert and one for fracture of the meniscalinsert. Both these patients also attended for review andwere functioning well at 5 years with HSS scores of 84and 98, respectively. One patient sustained an intra-operative fracture of the proximal tibia, which was fixedwith lag screws. This patient was still functioning wellat 5 years with a HSS score of 86. Two patients requiredWarfarin for deep venous thrombosis(DVT) and 1patient developed a clinical pulmonary embolism(PE).A subsequent ventilationyperfusion scan was performedwhich was equivocal, however, the patient was treatedon clinical findings as a PE. Two patients developedsuperficial infection withStaphylococcus aureus, How-ever, they were successfully treated with anti-biotics(see Table 3). To date there have been no proven casesof deep infection and no patients have undergone revi-sion surgery for aseptic loosening.

All patients who attended for clinical assessment hadstandardised AP and lateral radiographs taken. Satisfac-tory films were available for review in 68 out of 71knees(95.7%) (see Table 2). Radiological evidence oflucency was found in 21 knees out of 68(30.8%). Ofthis group 19 patients had lucent lines in zones 1–4below the tibial tray. None of these lucent lines wereover 1 mm thick as measured on radiographs. The othertwo lucent lines were found in zone 5 medial to the pegof the tibial component and in zone 1 behind the mostproximal part of the Femoral component(Fig. 1). Onreview of previous films there was no evidence ofprogressive lysis in any of these patients.

The clinical and functional results in these patientswere no different to those in patients with no evidence

169C.J. Wilson et al. / The Knee 10 (2003) 167–171

Fig. 1. AP radiograph of the Rotaglide TKR showing a thin radiolucent lines in zones 1 under the tibial component.

of lucency. The average HSS score in the group withlucent lines was 90.5(range 86–95) compared to 91.4.9for the group with no lucent lines. There is no statisticalsignificant difference between these two average scores.No patients showed evidence of progressive lysis onreview of previous radiographs.

4. Discussion

We feel the Rotaglide total knee Arthroplasty offerspatients a good clinical outcome at 5 years follow-up.The average HSS score for all patients is 90.9 with 63out of 67 (94.3%) knees achieving an excellent resultwith a score over 85 as described by Insall et al.w8x.To date there have been no deep infections or revisionsfor aseptic loosening. Two knees were revised(2.6%),which is a satisfactory result in comparison with otherreports w3,7,10x. One knee was revised for a fracturedmeniscal insert. This 66-year-old man had mild pain for4 weeks. He developed sudden pain in the knee after asimple fall and was unable to weight bear. He was takento theatre and a fractured 12-mm meniscal insert wasremoved and replaced with a 17-mm insert with goodrestoration of soft tissue balancing. Patellar mal-tracking,however, required a corrective lateral release. There islittle evidence of wear on this meniscal insert(Fig. 2).This patient subsequently had a satisfactory clinicaloutcome.

One patient was revised following dislocation of themeniscal insert. This 64-year-old man developed suddenpain while walking. X-rays showed dislocation of themeniscal insert. On surgical exploration the patient wasfound to have a lax knee in flexion and a dislocated9.5-mm meniscal insert. The knee was revised and goodstability achieved with a 12-mm insert. This patient hasmade good progress with satisfactory clinical functionto date. Dislocation of the meniscal insert is a significantproblem in mobile bearing knee replacementsw3,7x. Inthis case the flexion and extension gaps at initial surgerywere not balanced producing a knee which was lax inflexion.

The rates of other complications(Table 3) were alsorelatively low. Two patients developed superficial infec-tion post-operatively defined as wound erythema anddischarge with a positive bacterial culture. Methicillinsensitive Staphylococcus aureus was grown in bothpatients. These were treated successfully with anti-biotics and there was no need for surgical drainage.Both patients had satisfactory clinical scores on reviewand have not developed evidence of deep infection todate. Only 2 patients(2.8%) developed proven DVTand one a clinical PE. All these patients have madesatisfactory progress to date.

Both patients with meniscal complications wereimplanted early in our series. On revision both kneeswere lax in flexion due to improper soft tissue balancingat initial surgery. This problem was resolved with revi-

170 C.J. Wilson et al. / The Knee 10 (2003) 167–171

Fig. 2. Twelve millimetre Rotaglide meniscal insert with a fracture through one of the articular facets.

sion of the meniscal inserts and correction of soft tissuebalancing. We postulate that these complications mayhave been caused by laxity of these knees in flexion.This may lead to posterior subluxation of the mobilemeniscal in the flexed knee. In the case of meniscalfracture the insert may have been subluxed posteriorlyleading to excessive loading forces produced by femoralcomponent. On inspection of the fractured componentthere is little evidence of wear on the articular surface.However, the appearance of the fractured surface wassuggestive of repetitive strain and damage of the poly-ethylene until if finally resulted in failure(Fig. 2). Inthe case of meniscal dislocation this insert may alsohave subluxed posteriorly in flexion allowing it todislocate. In our practice we therefore recommend thatsignificant care is taken to balance the flexion andextension gaps to avoid producing a lax knee in flexion.There have been no further meniscal complications inour series of over 300 knees to date.

5. Conclusions

The Rotaglide total knee prosthesis offers patients anexcellent clinical outcome at a minimum of 5 yearsfollow-up. 94.3% patients had an HSS score of 85 ormore on clinical and functional review. All other patientsscored between 78 and 84. Most patients were satisfiedwith control of pain and their overall functional out-come. Complications are relatively infrequent and only2 patients have required revision both for meniscal

problems early in the series. Both these revisions maybe related to incorrect tissue balancing of the flexionand extension gaps early in our learning curve with thisprosthesis. These meniscal complications highlight theexacting nature of the surgical technique required forthis prosthesis, particularly for the surgeon used toimplanting fixed bearing TKR’s which are more forgiv-ing of sub-optimal soft tissue balancing.

There have been no subsequent meniscal problems inour full series of over 300 knees to date and the 2 kneeswith revised meniscal bearings have had excellent longterm outcomes. No Rotaglide knees have so far beenrevised for loosening or other implant failure.

References

w1x Brooks S. The Rotaglide Knee, The Solihull experience at nineyears follow up. Data supplied by Corin Medical Ltd.

w2x Polyzoides AJ, et al. Design characteristics, experimentalstudies and ten years of clinical experience with fully conform-ing mobile bearing knee prosthesis. Proceedings of the Inter-national Symposium of the Knee, April 1999.

w3x Callaghan JJ, et al. Mobile-Bearing Knee Replacement: Con-cepts and results. AAOS Instructional Course Lectures2001;50:431–449.

w4x Tsakonas A, Polyzoides AJ. Reduction of polyethylene in acongruent meniscal knee prosthesis. Acta Orthop Scand.1997;68(Suppl 275):127–131.

w5x Polyzoides AJ. The Rotaglide total knee Arthroplasty. J Arthro-plasty 1996;11:453–459.

w6x Crova M, Olivero C. Rotating knee prosthesis, surface or hingereplacement? Orthopade 2000;29:543–544.

171C.J. Wilson et al. / The Knee 10 (2003) 167–171

w7x Polyzoides AJ, Tsakonas A. The Rotaglide Knee replacement:results of the first 311 cases. Proceedings of the RotaglideTotal Knee Course, 29th October 1993.

w8x Insall JN, et al. Rational of the knee society clinical ratingsystem. Clin Orthop. 1989;248:13–14.

w9x Ewald FC. The knee society total knee Arthroplasty roentgen-

ographic evaluation and scoring system. Clin Orthop.1989;248:9–12.

w10x Meding JB, Keating EM. Overview: long-term follow up:predicting the success of a total knee Arthroplasty. Clin Orthop.2001;338:7–9.