15-Year Follow-up Study of Total Knee Arthroplasty in Patients With Rheumatoid Arthritis

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1 The Journal of Arthroplasty Vol. 18 No Year Follow-up Study of Total Knee Arthroplasty in Patients With Rheumatoid Arthritis Jun Ito, MD, PhD, Tomihisa Koshino, MD, PhD, Renzo Okamoto, MD, PhD, and Tomoyuki Saito, MD, PhD Abstract: In 25 patients with rheumatoid arthritis, 36 cases of cemented Kinematic total knee arthroplasty were reviewed clinically and radiographically at 13 to 19 years after surgery. The mean age at the time of surgery was years. According to the follow-up results evaluated with the Hospital for Special Surgery knee scoring system, 28 knees (77.7%) were classified as good or excellent. The mean flexion angle at follow-up evaluation was ( ). At the tibial or femoral bone cement interfaces, a radiolucent line was seen in 10 of 36 knees (27.8%) at follow-up evaluation. The survival rate of prostheses with revision as the endpoint was estimated to be 93.7% at 15 years. Kinematic total knee arthroplasty in rheumatoid arthritis patients provided a good long-term outcome. Key words: total knee arthroplasty, kinematic prosthesis, rheumatoid arthritis, survivorship analysis, long-term results Elsevier Inc. All rights reserved. Total knee arthroplasty (TKA) provides good pain relief and functional recovery in patients who have limited walking ability with persistent knee pain caused by chronic rheumatoid arthritis. The longterm results of TKA for osteoarthritic and rheumatoid knees have been reported, and the clinical results were satisfactory [1 6]. The long-term results up to 10 years for rheumatoid patients have been reported by several authors [7 11], with survival rates of the prostheses of 81% to 93% [7 11]. Laskin [7] reported the results of use of a total condylar knee prosthesis for rheumatoid patients up to 10 years after surgery. These knees had an all-polyethylene tibial component and only one size From the Department of Orthopaedic Surgery, Yokohama City University School of Medicine, Yokohama, Japan. Submitted September 27, 2002; accepted April 15, No benefits or funds were received in support of this study. Reprint requests: Jun Ito, MD, PhD, Department of Orthopaedic Surgery, Yokohama City University School of Medicine, Yokohama, Japan Elsevier Inc. All rights reserved /03/ $30.00/0 doi: /s (03) of femoral component. At 10 years, 85% of the tibial components had some radiolucency on anteroposterior radiographs. With revision as the endpoint, the survival rate was 81% at 10 years after surgery. A better survival rate was reported for patients with rheumatoid arthritis than osteoarthritis [8,9]. The Kinematic prosthesis has a posterior cruciate sparing design in both the anteriorly joined type and the posterior retention type, made from cobalt-chromium. A metal-backed tibial prosthesis was developed for better fixation of the prosthesis to the bone. Further, the femoral and tibial geometry was designed to obtain a greater flexion angle. Wright et al. [12] reported 90% excellent or good medium-term (5 9 years) results with Kinematic total knee arthroplasty. The long-term survival rates from 10 to 18 years have been reported for the Kinematic implant [3]. The purpose of the present study was to assess the long-term results of total knee arthroplasty with a Kinematic prosthesis with or without sacrificing the anterior cruciate ligament in patients with rheumatoid arthritis. 984

2 Long-Term Results of Kinematic Prostheses Ito et al. 985 Table 1. State of Patients at Follow-up Evaluation Patients, n (%) Knees, n (%) Evaluated 25 (26.9) 36 (28.2) Revised 6 (6.5) 6 (4.7) Inadequate* 3 (3.2) 3 (2.3) Did not return 5 (5.4) 6 (4.7) Died 38 (40.8) 50 (39.0) Lost 16 (17.2)/3 (3.2) 27 (21.1)/5 (3.9) Total 93(100.0) 128(100.0) *Three patients (3 knees) could not be evaluated because of other disorders (1 patient with cervical myelopathy and 2 with chronic renal failure). Five patients (6 knees) were not examined, because they did not return to the hospital. Three patients (5 knees) were included in the cases lost to follow-up because the year when the patient died was not clear. Materials and Methods From 1981 to 1987, 128 cases of primary total knee arthroplasty with a Kinematic anteriorly joined (AJ) type or posterior cruciate retention (PCR) were performed in 93 patients with rheumatoid arthritis at our University Hospital and its affiliated hospitals. Cement was used at the insertion of implants. The patella was not resurfaced in any patient at primary surgery except in 3 knees with anterior knee pain and articular deformity in the patellofemoral joint on radiographs. At follow-up, 38 patients (50 knees) had died, 16 patients (27 knees) had been lost to follow-up, and 3 patients (3 knees) could not be evaluated because of other disorders (1 patient with cervical myelopathy and 2 with chronic renal failure). Five patients (6 knees) were not examined, because they did not return to the hospital. Six patients (6 knees) underwent revision surgery. None of the patients who died had undergone revision surgery or experienced complications related to their knees while they were alive. Therefore 36 knees in 25 patients were available for clinical and radiographic evaluation. Three patients (5 knees) who died were included in the cases lost to follow-up, because the year in which they died was not clear. The prostheses in these patients were not revised while they were alive (Table 1). The study included 35 knees in women and one knee in a man. The mean patient age at surgery was years (range, years). The mean patient height was cm (range, cm), and the mean weight was kg (range, kg). Eleven patients had bilateral involvement. Twenty-eight knees received insertion of an anteriorly joined type of Kinematic prosthesis and 8 knees received a posterior cruciate retention type of Kinematic prosthesis. Among these knees, 2 underwent patellar resurfacing at initial surgery, and another 3 knees underwent additional patellar resurfacing during the follow-up period. Total hip arthroplasty was performed in 6 patients. Total ankle arthroplasty was performed in 2 patients. Ankle fusion was performed in 1 patient. Femoral head replacement for femoral neck fracture was performed in 1 patient. Other limb surgery was performed in 6 patients. The patients were evaluated clinically using the rating systems of the Hospital for Special Surgery (HSS) [13] and the Knee Society (KS) [14]. In the KS rating system, 2 scores are assigned: one for pain, range of motion, and stability (knee score) and another for walking, stair climbing, and use of walking aids (function score). Data were obtained from anteroposterior radiographs taken with the patient standing and lateral radiographs. Radiolucency at the bone cement interface was rated in 7 zones in the anteroposterior view of the tibial component, 5 zones in the lateral view of the tibial component, and 7 zones in the lateral view of the femoral component (Table 2). Radiolucent lines were divided into 4 grades; none (grade I), 1 mm (grade II), 1 2 mm (grade III), and 2 mm (grade IV). Zone Grade I None Table 2. Radiolucencies Grade II 1 mm Grade III 1 mm, 2 mm Grade IV 2 mm Total Lateral femoral radiolucencies (13.9%) (8.3%) Anteroposterior tibial radiolucencies (8.3%) (5.6%) (13.9%) (13.9%) Lateral tibial radiolucencies (5.6%) (5.6%)

3 986 The Journal of Arthroplasty Vol. 18 No. 8 December 2003 Survivorship analysis was performed using the Kaplan-Meier method, and a survival life table was created using actual methods [15]. Three endpoints were used: (i) death, (ii) removal or revision of the prosthesis, (iii) additional patellar resurfacing. Patients who died or were lost to follow-up evaluation were dropped from the life tables in the second and third analyses. Calculation of the number at risk for each interval and the annual success rates was performed. The survival rate was calculated by successive multiplication of the annual success rates. Statistical analysis was performed with paired t-test, Wilcoxon signed rank test, Mann-Whitney U test, and Fisher s exact method for evaluation of the preoperative and postoperative clinical knee scores. The log-rank test was used to assess statistical significance after stratification of the survivorship data. Probability values less than.05 were considered significant. Clinical Evaluation Results Knee scores as determined by the HSS score improved from a preoperative mean of points (range, points) to points (range, points) at the follow-up evaluation (P.0001, by Wilcoxon signed rank test). Average KS knee scores improved from a mean of points preoperatively to points at the follow-up evaluation (P.0001, by Wilcoxon signed rank test). Function as determined by KS score improved from a mean of points preoperatively to points (P.0001 by Wilcoxon signed rank test) at the follow-up evaluation. Before surgery, 28 (77.8%) of the 36 knees had moderate or severe pain on weight bearing. At the latest follow-up evaluation, moderate or severe pain was not noted in any knee (P.0001 by Fisher s exact method), and no pain was noted in 27 knees (75%). The mean KS score for pain increased from points preoperatively to points at the follow-up evaluation (P.0001, by Wilcoxon signed rank test). The mean range of motion of the knees was to of flexion preoperatively. At the latest follow-up evaluation, the mean range of motion was to of flexion. Therefore, extension of the knee increased (P.0001, by paired t-test), and flexion decreased after arthroplasty compared with preoperative values. Flexion contracture of more than 20 was seen in 23 knees (19 patients) preoperatively and 2 knees (2 patients) postoperatively. Flexion of less than 70 was seen in 5 knees before surgery and in 1 knee at follow-up evaluation. Preoperatively, none of the patients could walk more than 5 blocks, 12 patients (18 knees) could walk indoors only, and 5 patients (7 knees) could not walk. At the latest evaluation, 9 patients (14 knees) could walk more than 5 blocks. The walking score determined by KS score increased from a mean of points preoperatively to points at follow-up evaluation (P.0001 by Wilcoxon signed rank test). Preoperatively, 18 patients (25 knees) could not climb stairs at all. At the latest evaluation, 5 patients (7 knees) could not climb stairs. The KS score for stairs increased from a mean of points preoperatively to points at follow-up evaluation (P.0001, by Wilcoxon signed rank test). Preoperatively, 6 patients (9 knees) did not use a walking aid, and 7 patients (10 knees) used a wheelchair. At the latest evaluation, 11 patients (15 knees) did not use a walking aid, and 3 patients (4 knees) used a wheelchair. A significant difference was found in scores of the following items by Mann-Whitney U test between knees with resurfacing of the patella (resurfacing: 5 knees; resurfacing at initial surgery: 2 knees; additional patellar resurfacing: 3 knees) and without (non: 31 knees) (mean function score: none, ; resurfacing , P.0197; mean walking score: non , resurfacing , P.0334). Preoperative function score and walking score failed to show any statistically significant differences between the nonresurfacing and resurfacing groups. Complications Related to Knees Postoperative infection occurred in 3 knees (2.3%; 3 of 128 knees) 10 days, 4 months, and 9 months after surgery. The infection resolved with intravenous infusion of antibiotics or irrigation without revision in 2 knees. Implant was removed in one knee. Supracondylar fracture occurred in 2 knees (1.6% or 2 of 12 knees) as a result of falls while walking. The patients were treated without a cast for the rest of the affected limb, because the fractures were nondisplaced. One knee sustained a supracondylar fracture at 13 years after surgery. The other patient experienced a supracondylar fracture at 14 years after surgery.

4 Long-Term Results of Kinematic Prostheses Ito et al. 987 Additional Patella Resurfacing Six knees (5 patients) of 128 knees underwent additional patella resurfacing because of patellofemoral pain. Of these 6 knees, 3 were evaluated clinically. Revision Six knees of 6 patients underwent revision surgery. One knee was revised because of infection 4 months after the initial surgery. Two knees sustained breakage of the tibial metallic tray concomitant with aseptic loosening. They required revision surgery at 3 years and 13 years, respectively, after the initial surgery. Wear of the patellar dome and loosening of the femoral component were found on roentgenography 5 years after resurfacing of the patella in one knee; revision surgery was performed 18 years after the initial joint arthroplasty. One knee had patellofemoral joint pain and synovitis without loosening of the components 13 years after initial joint arthroplasty. Patellar resurfacing surgery was planned for this knee. At surgery, arthrotomy revealed that the polyethylene plate was worn away and the tibial metal tray was scratched. Therefore, the tibial component and the polyethyleneinserter were replaced in addition to patellar resurfacing. One knee underwent revision surgery at another hospital because of loosening 10 years after surgery. Roentgenographic Evaluation Knee Alignment. The overall mean alignment was a femorotibial angle (FTA) of as measured on the preoperative radiograph in the standing position. The overall mean postoperative alignment was a femorotibial angle of as measured on the postoperative radiograph at follow-up evaluation. Preoperatively, 3 knees had more than 180 of varus angulation (range, 3 to 15 ). Postoperatively, the alignment had been corrected to a mean femorotibial angle of (range, 166 to 175 ). Preoperatively, 33 knees were in neutral or valgus alignment (mean, 10 of valgus angulation; range, 0 to 24 ). Postoperatively, the knees had been corrected to a mean femorotibial angle of (range, 156 to 197 ). Position of Components. At follow-up evaluation, the mean position of the femoral component ( ) was (range, ), and the mean position of the tibial component ( ) was (range, ). The mean angle of the femoral component ( ) was (range, Fig. 1. Survival curves of original data and worst-case scenario for the life of the patients. Graph shows a 45.2% survival rate at 15 years for original data and 35.0% in the worst-case scenario ), and the mean angle of the tibial component ( ) was (range, ). Three knees had a angle less than 0. However, these knees developed no complications. The angles of the 2 knees that developed supracondylar fractures were 6 and 21, respectively. Neither of these 2 knees had a notch on the femur. Radiolucent Lines. At the tibial or femoral bone cement interfaces, radiolucent lines were seen in 10 of 36 knees (27.8%) during a follow-up period of more than 13 years. Five knees (13.9%) had a radiolucent line associated with the femoral component. Ten knees (27.8%) had a radiolucent line associated with the tibial component. Five radiolucent lines were seen in zones l and 3 in zone 2 at the femoral bone cement interface. In one knee, a radiolucent line more than 2 mm thick (grade IV) was seen at both the femoral and tibial bone cement interfaces. We noted 3 radiolucent lines in zone l, 2 in zone 2, 5 in zone 3, 5 in zone 5, 2 in zone 8, and 2 in zone 9 at the tibial bone cement interface. No knee had a radiolucent line beneath either the femoral or tibial tray. No correlation was noted between radiolucency and variables such as age, body weight, type of component, and alignment (Table 2). Survivorship Survivorship was calculated using the method of Kaplan and Meier [15]. The survival rate for all patients by the life-table method was estimated to be 74.3% at 10 years, 45.2% at 15 years, and 39.2% at 19 years (Fig. 1). With revision as the endpoint, the survival rate of the prostheses was estimated to be 98.3% at 10 years, 93.7% at 15 years, and 89.8% at 19 years (Table 3). The survival

5 988 The Journal of Arthroplasty Vol. 18 No. 8 December 2003 Table 3. Survivorship Analysis of Kinematic Knee Arthroplasty With Revision as Endpoint Years Since Surgery Number at Start Revision Withdrawn Lost to Follow-up Died Censored (alive) Number at Risk Annual Failure Rate (%) Annual Success Rate (%) Survival Rate((%) 0 to to to to to to to to to to to to to to to to to to to to rate of the AJ type was estimated to be 96.4% at 10 years, 92.7% at 15 years, and 88.5% at 19 years. That of the PCR type was 100.0% at 19 years. No significant differences were seen in the survival rates between the AJ and PCR types (Fig. 2). With additional patellar resurfacing as the endpoint, the survival rate of a nonresurfaced patella was 94.2% at 10 years, 92.6% at 15 years, and 92.6% at 19 years (Table 4). The survival rate of the patella of the AJ type was estimated to be 96.4% at 10 years, 94.6% at 15 years, and 94.6% at 19 years. That of the patella of the PCR type was 88.2% at 10 to 19 years. No significant difference was seen in the survival rate between the AJ type and PCR type (Fig. 3). Worst-Case Scenario. The worst-case scenario was that all patients considered lost to follow-up underwent revision surgery or patellar resurfacing just after loss. In these cases, with revision as the endpoint, the rate of prostheses survival was estimated to be 80.6% at 10 years, 76.7% at 15 years, and 72.2% at 19 years. With additional patellar resurfacing as the endpoint, the rate of survival of nonresurfaced patellas was estimated to be 78.8% at 10 years, 76.0% at 15 years, and 73.5% at 19 years (Figs. 2, 3). Discussion Fig. 2. Survival curve of original data and worst-case scenario for the prostheses, with revision as the end point. Graph shows 93.7% survival rate of the prosthesis at 15 years for original data and 76.7% in the worst-case scenario. The survival rate of the anteriorly joined type was estimated to be 92.7% at 15 years. The survival rate of the posterior cruciate retention type was estimated to be 100.0% at 15 years. In previous reports of TKA in rheumatoid patients, the clinical results were excellent or good in 77% to 81% of patients [6,7,11]. A prosthesis other than the Kinematic implant was used in these studies. The functional status of rheumatoid patients after TKA remained far below that of patients with osteoarthritis treated with TKA [12]. This was believed to be caused by the polyarticular involve-

6 Long-Term Results of Kinematic Prostheses Ito et al. 989 Table 4. Survivorship Analysis for Nonresurfaced Patella, With Patellar Resurfacing as Endpoint Years Since Surgery Number at Start Resurfacing Withdrawn Revision Lost to Follow-up Died Censored (alive) Number at Risk Annual Failure Rate (%) Annual Success Rate (%) Survival Rate (%) 0 to to to to to to to to to to to to to to to to to to to to ment of rheumatoid arthritis and the steadily declining functional status that can occur in the long term [16]. In our cases, 6 patients underwent surgery on other joints. Although other joints were involved in rheumatoid arthritis, excellent or good results in the HSS score were obtained in 77.7% of patients in our series after a mean follow-up of 15 Fig. 3. Survival curve of original data and worst-case scenario for the nonresurfaced patella, with additional patellar resurfacing as the endpoint. Graph shows a 92.6% survival rate at 15 years for original data and 76.0% in the worst-case scenario. The survival rate of the anteriorly jointed type was estimated to be 94.6% at 15 years. The survival rate of the posterior cruciate retaining type was estimated to be 88.2% at 15 years. years. Good to excellent long-term results were reported in 70% to 89% of patients with the Kinematic prosthesis [3,10,17,18]. Good or excellent clinical results in Japanese Orthopaedic Association (JOA) scores at 10 years were reported in 70% of patients with rheumatoid knees treated with the Kinematic prosthesis by Hanyu et al. [10]. Pain score and range of motion are usually outside the influence of other disorders. Pain relief was well maintained in previous reports [4,6,7,11,17]. In our cases, 27 of 36 knees had no pain. FTA was 165 to 185 in these knees. Van Loon et al. [4] reported that 48 of 52 knees (92%) had no pain or only occasional pain. Malkani et al. [17] reported no pain in 70% of knees. Laskin [7] reported that knees with a low pain score had malalignment or malpositioning of the component, especially in the tibia. In our cases, no significant difference in FTA was found between knees with no pain and knees with pain. All of our cases had synovitis preoperatively, and synovectomy was performed at surgery. One knee showed synovitis caused by the polyethylene wearing postoperatively. Laskin [7] reported that synovitis recurred in only 3 knees over 10 years after surgery without synovectomy in knees with rheumatoid arthritis. They suggested that the immune response that caused recurrence of synovitis could be controlled by removing all of the articular cartilage and extensive synovectomy was unnecessary [7].

7 990 The Journal of Arthroplasty Vol. 18 No. 8 December 2003 The prevalence of radiolucent lines was reported to be 20% to 60% [17 19]. Uematsu et al. [18] reported 7% on the femoral side and 20% on the tibial side in 616 knees. In that study, 371 knees were followed up for less than 2 years, and the maximum follow-up period was 7 years. A higher prevalence was reported over a longer follow-up period [18]. Malkani et al. [17] reported a prevalence of 60% at a mean of 10 years after surgery. Approximately 60% of these patients were diagnosed with osteoarthritis [17]. Ewald et al. [19] reported that 18% (22 knees) of 124 consecutive cases with a Kinematic condylar prosthesis had incomplete, nonprogressive radiolucent lines less than 1 mm in width at the tibial bone cement interface. In our cases, the prevalence was 27.8% at 13 years or more after surgery. One of the reasons for the low prevalence may be that all patients had rheumatoid arthritis, which impairs the patient s activity because of multiple joint destruction and is associated with a lower body weight. In our series of evaluated radiographs, postoperative alignment was 5 of valgus, which is considered to be ideal. Whether or not malalignment of the knee affects the clinical results or radiolucent lines is a most important consideration, especially in the long term. In the 3- to 4-year follow-up results of Ewald et al. [19], the cases of malpositioning of the tibial component such as varus positioning showed radiolucent lines. Furthermore, the prevalence of radiolucent lines was significantly higher in cases with a varus-positioned tibial component than in those with the ideal position. Conversely, the presence of radiolucent lines around the femoral component was not correlated with the positioning of the femoral component [19]. With another prosthesis such as the total condylar prosthesis, varus positioning of the tibial component was associated with a high prevalence of loosening of the tibial component. A properly aligned tibial component showed the most successful results [7]. In rheumatoid knees, Laskin [7] indicated that varus positioning of the tibial component was significantly correlated with radiolucency at the bone cement interface in a 10-year follow-up study. In our cases, the correlation between radiolucent lines and malpositioning was not significant. However, 1 knee with a clear zone of more than 2 mm had malpositioning of the femoral and tibial components. The mean body weight in our cases was 49.2 kg, which is lighter than the mean body weight of 70 kg in the previous report [17]. Complications after TKA other than loosening and infection consisted of fracture of the bone around the prosthesis [20,21], breakage of the metallic tray [22], granulomatous reaction [23], skin necrosis, deep vein thrombosis, and nerve palsy. In our study, one knee had a supracondylar fracture caused by minor trauma. Range of motion of the knee was only 15 of flexion before fracture. Limited range of motion could be a risk factor for supracondylar fracture of the knee. One knee required revision surgery because of a granulomatous reaction after additional patellar resurfacing. Breakage of the tibial tray was seen in 2 knees, both of which had loosening at the cement bone interface in the tibia. In the evaluation of the long-term results of TKA, deaths are inevitable. Patients with rheumatoid arthritis showed a marked increase in deaths resulting from infection or sepsis and problems associated with the rheumatoid process itself. In our study, survivorship of all patients by the life-table method was estimated to be only 45.2% at 15 years. Hanyu et al. [10] reported a 56% survival rate of patients at 10 years, with death as the endpoint. On the other hand, the survival rate at 10 years in the control group was 80%. The survivorship of the Kinematic prosthesis at 10 years was previously reported to be 90% to 98% [3 5,10,24]. Hanyu et al. [10] reported 93% survivorship of the prosthesis in rheumatoid arthritis patients with a PCR model or a posterior stabilizer model. In their study, the number of patients lost to follow-up is not clear. Weir et al. [24] reported prosthesis survivorship of 92% at 10 years with the Kinematic prosthesis. The majority of their patients had rheumatoid arthritis as well. Prosthesis survivorship at 10 years in patients, including a large number of cases of osteoarthritis, was reported to be 98% by Gill [3], 96% by Malkani et al. [17], and 97% by Scuderi et al. [25]. Patients with rheumatoid arthritis and osteoarthritis were equal in number in the report by van Loon et al. [4], and the prosthesis survivorship at 10 years was 90%. TKA for rheumatoid arthritis and that for osteoarthritis are not similar in terms of the activity of patients, osteoporosis around the knee joint, disorder of other joints, and age at surgery. Therefore, the data of follow-up results and survival rate are not exactly comparable if the prosthesis, disease population and age at surgery are considered. The prosthesis survival rate in our cases was satisfactory, being close to 94% at 15 years. Rand et al. [9] reported that the most favorable variables for prolonged survival of TKA were primary arthroplasty, a diagnosis of rheumatoid arthritis, an age of 60 years or more, and use of a resurfacing condylar prosthesis with a metal-backed tibial component. Our patients had 3 of these 4 favorable variables.

8 Long-Term Results of Kinematic Prostheses Ito et al. 991 Sacrifice of the anterior cruciate ligament changes the kinematics of knee movement, and may cause a difference in prostheses survivorship. According to our results, the AJ group and PCR group did not show a significant difference in prosthesis survival rate. Real survivorship including patients who were lost to follow-up might be worse than that determined from the original data. This paper presents a worst-case scenario that assumed all patients lost to follow-up failed. Weir et al. [24] reported a worstcase prosthesis survivorship of 89% at 10 years. In our study, worst-case survivorship was 80.6 % at 10 years and 76.7% at 15 years, because 16 patients were lost to follow-up. Three patients (5 knees) without revision were included in the cases lost to follow-up because the year in which the patient died was not clear. Therefore, real survivorship should be better than the worst case. However, the number of patients lost to follow-up was not small. From this aspect, our study of survivorship has limitation in its accuracy. In our study, a patellar component was not inserted at the initial surgery except in 3 knees. In 6 knees in 5 patients, however, the patella was additionally resurfaced because of anterior knee pain. With patellar resurfacing as the endpoint, survivorship was 92.6% at 15 years. The remaining cartilage in cases of TKA may cause persistent inflammation of the knee. However, the majority of our patients did not complain of knee pain, and signs of arthritis such as synovitis and joint effusion were not noted at follow-up evaluation. At follow-up evaluation, the patella was resurfaced with a patellar component in 5 of 36 knees. The function scores of these 5 knees were significantly lower than those of the other 30 knees. Boyd et al. [26] retrospectively evaluated knees that had undergone TKA with or without patellar resurfacing. In that report, the overall complication rate was 4% in the group that had undergone resurfacing and 12% in the group that had not undergone resurfacing [26]. Chronic pain was noted significantly more frequently in inflammatory arthritis than in degenerative osteoarthritis after surgeries without resurfacing. According to this result, Boyd et al. [25] recommended resurfacing of the patella at initial TKA. Hanyu et al. [10] reported that patellar resurfacing was performed in 3 of 88 knees that did not undergo patellar arthroplasty at initial surgery. Currently, the patellar component is replaced at TKA in patients with rheumatoid arthritis. Conversely, inadequate patellar tracking and component position were reported to cause a high prevalence of complications [27]. The long-term survivorship of the patellar component and complications involving the patellofemoral joint at our hospital will show the benefits and disadvantages of patellar resurfacing. Total knee arthroplasty is the only option for joint deformity or cartilage destruction of the knee in rheumatoid arthritis. Hemiarthroplasty and osteotomy do not improve inflammation and the continuous destruction of residual joint cartilage of the knee joint. Therefore, good long-term results are expected up to 20 years after surgery in knees with rheumatoid patients. The results of this study suggest that knee function was well maintained and the prosthesis survival rate was still acceptable during the long-term after 13 to 19 years. References 1. Ranawat CS, Boachie-Adjel O: Survivorship analysis and results of total condylar knee arthroplasty: eightto 11-year follow up period. Clin Orthop 226:6, Tew M, Wauch W: Estimating the survival time of knee replacements. J Bone Joint Surg Br 64:579, Gill GS, Joshi AB: Long-term results of Kinematic condylar knee replacement: An analysis of 404 knees. J Bone Joint Surg Br 83:355, Van Loon CJ, Wisse MA, de Waal Malefijt MC, et al: The kinematic total knee arthroplasty: A 10- to 15 year follow-up and survival analysis. Arch Orthop Trauma Surg 120:48, Ansari S, Ackroyd CE, Newman JH: Kinematic posterior cruciate ligament-retaining total knee replacements: a ten-year survivorship study of 445 arthroplasties. Am J Knee Surg 11:9, Kristensen O, Nafei A, Kjaersgaard-Andersen P, et al: Long-term results of total condylar knee arthroplasty in rheumatoid arthritis. J Bone Joint Surg Am 74: 803, Laskin RS: Total condylar knee replacement in patients who have rheumatoid arthritis: a ten-year follow-up study. J Bone Joint Surg Am 72:529, Ranawat CS, Flynn WF Jr, Saddler S, et al: Long-term results of the total condylar knee arthroplasty: a 15-year survivorship study. Clin Orthop 286:94, Rand J, Ilsrup DM: Survivorship analysis of total knee arthroplasty: cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am 73:397, Hanyu T, Murasawa A, Tojo T: Survivorship analysis of total knee arthroplasty with the Kinematic prosthesis in patients who have rheumatoid arthritis. J Arthroplasty 12:913, Rodriguez JA, Saddler S, Edelman S, Ranawat CS: Long-term results of total knee arthroplasty in class 3 and 4 rheumatoid arthritis. J Arthroplasty 11:141, 1996

9 992 The Journal of Arthroplasty Vol. 18 No. 8 December Wright J, Ewalds FC, Walker PS, et al: Total knee arthroplasty with the Kinematic prosthesis: results after five to nine years: a follow-up note. J Bone Joint Surg Am 70:491, Insall J, Ranawat CS, Scott WN, Walker P: Total condylar knee replacement: preliminary report. Clin Orthop 120:149, Ewald FC: The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop 248:9, Armitage P, Berry G: Statistical methods in medical research, second edn. Oxford, Blackwell Scientific, Pincus T: The paradox of effective therapies but poor long-term outcome in rheumatoid arthritis. Semin Arthritis Rheum 2:2, Malkani AL, Rand JA, Bryan RS, Wallrichs SL: Total knee arthroplasty with the Kinematic condylar prothesis: a ten-year follow-up study. J Bone Joint Surg Am 77:423, Uematsu O, Hsu EP, Kelley KM, et al: Radiographic study of Kinematic total knee arthroplasty. J Arthroplasty 2:317, Ewald FC, Jacobs MA, Miegel RE, et al: Kinematic total knee replacement. J Bone Joint Surg Am 66: 1032, Figgie MP, Goldberg VM, Figgie HE III, et al: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 5:267, Merkel KD, Johnson EW Jr.: Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am 68:29, Scott RD, Ewald FC, Walker PS: Fracture of the metallic tibial tray following total knee replacement: report of two cases. J Bone Joint Surg Am 66:780, Dannenmaier WC, Haynes DW, Nelson CL: Granulomatous reaction and cystic bony destruction associated with high wear rate in a total knee prosthesis. Clin Orthop 198:224, Weir DJ, Morgan CG, Pinder IM: Kinematic condylar total knee arthroplasty: 14-year survivorship analysis of 208 consecutive cases. J Bone Joint Surg Br 78: 907, Scuderi GR, Insall JN, Windsor RE, Moran MC: Survivorship of cemented knee replacements. J Bone Joint Surg Br 71:798, Boyd AD, Ewald FC, Thomas WH, et al: Long-term complication after total knee arthroplasty with or without resurfacing of the patella. J Bone Joint Surg Am 75:674, Brigk GW, Scott RD: The patellofemoral component of total knee arthroplasty. Clin Orthop 231:163, 1988

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