Sto Indus Knee 2

Dr N Purushothama Rao MS Orth, MCh Orth UK.,MRCS Glasgow MRCS Edinburgh

Senior Resident in Orthopaedics, Government General Hospital/ Rangaya Medical College, Kakinada

Prof Dr Y Nageswar Rao MS Orth, Professor and Head of the Dept Orthopaedics, RMC/GGH Kakinada

Asst Prof: Dr M Vittal MS Orth, Dr Shyam Sundar MS Orth, Dr Pardhasardhi MS Orth, S/R :Dr Aditya Krishna MS MCh Orth, PGs: Dr Seshagiri, Dr Aziz

Not funded by any Surgical Industry

Not received any grants

DisclosuresDisclosures

DisclosuresDisclosures

Squatting

Introduction

Principles of TKR

Design rationale of Indus Knee

Purpose of our study, Materials & Methods

Results & Discussion

Conclusion

OUTLINE

OUTLINE

TKA is one of the most successful and the best results for TKA at 10–15 yrs. compare to or surpass the best result of THA.

Nearly 30000 people undergo joint replacements in India per year with a 25% increase each year.

Knee osteoarthritis is the commonest indication for joint replacement.

Introduction

Introduction

Femur size of Asians differs from that of Caucasians TJ P Implants designed & manufactured to accommodate the knee anatomy of Western Caucasians, not Asians, The smallest size from each Western prosthesis company is used, may be too big for some Asian subjects.

Chaichankul** and Cheng ##reported that Thai & Chinese population knees were mismatched and too small, respctively, for several Western prostheses, it is likely that results would be similar to other Asian populations.

For Indian subjects, there is no clear evidence about how often incorrect sizing using Western prostheses occurs

This limitation suggests the need for a prosthesis developed for an Asian population, such as the Indians, who often require a higher flexion for most of their daily social habits and customs

Is there a need for development of

a knee prosthesis for an Asian population

Is there a need for development of

a knee prosthesis for an Asian population

**Chaichankul C, Tanavalee A, Itiravivong P: Anthropometric measurements of knee joints in Thai population: correlation to the sizing of current knee prostheses. Knee 2011, 18:5–10.

##Cheng FB, Ji XF, Lai Y, Feng JC, Zheng WX, Sun YF, Fu YW, Li YQ: Three dimensional morphometry of the knee to design the total knee arthroplasty for Chinese population. Knee 2009, 16:341–347

**Chaichankul C, Tanavalee A, Itiravivong P: Anthropometric measurements of knee joints in Thai population: correlation to the sizing of current knee prostheses. Knee 2011, 18:5–10.

##Cheng FB, Ji XF, Lai Y, Feng JC, Zheng WX, Sun YF, Fu YW, Li YQ: Three dimensional morphometry of the knee to design the total knee arthroplasty for Chinese population. Knee 2009, 16:341–347

Two design modifications allow maximal flexion at the knee

The radius of curvature of the posterior condyle of the femoral comp (J curve) has been reduced, thereby increasing the posterior condylar offset. The total thickness remains the same. The original offset is reproduced. This helps in gaining more femoral rollback and more flexion.

A 4° slope is incorporated in the tibial insert and a 3° slope in the metal base plate , a total of 7° Posterior Tibial Slope to aid in increase of flexion22 **

** Bellemans et al., The influence of tibial slope on maximal flexion after TKA.Knee Surg Sports Traumatol Arthrosc. 2005;13:193–6

Design rationale of Indus Knee The ethnic, anatomical & cultural variations in the Indian population have

prompted the need for development of the INDUS KneeIt is a posterior cruciate substituting design where femoral rollback occurs by a

post & cam mech.

Design rationale of Indus Knee The ethnic, anatomical & cultural variations in the Indian population have

prompted the need for development of the INDUS KneeIt is a posterior cruciate substituting design where femoral rollback occurs by a

post & cam mech.

The INDUS prosthesis is designed so as to keep the thickness of the posterior condyle equivalent to the thickness of the distal condyle.

The cam and post have been placed in such a way that the removal of the box in the center is much less; hence, patellofemoral complications are much lower.

The purpose of this study is to analyze the short term follow-up results using the INDUS prosthesis.

Introduction

Introduction

Alignment

Balancing

Correct Bony cuts, Component sizes, Cementation

Deformity correction (incl Patellar Tracking)

Sizing of components

Principles of TKRABCD S


To attain Knee flexion

beyond 150 degrees

without compromising wear,

Polyethylene contact stresses,

Patello femoral Tracking, or stability



1. The J curve is modified to a greater ROM

2. Posterior condyles

a) Reduced radii of curvature

b) Increase in thickness c) Requires additional

resection of the posterior condyles

Design Features of The INDUS KneeThe J curve modified- Posterior condyles design &

thickness

Design Features of The INDUS KneeThe J curve modified- Posterior condyles design &

thickness

Sloped Box

Proportional Box width

25% - 45% less bone resection

Design rationale of Indus KneeLess Bone resection than the conventional PS Knee

Design rationale of Indus KneeLess Bone resection than the conventional PS Knee

PS Knee INDUS Knee


THE NEW 3RD ARTICULATING CONDYLE


THE NEW 3RD ARTICULATING CONDYLE

Conforming Geometry

between the Cam and

the Post ( 3rd Condyle)

Cam

Post

A third joint was designed between the post & the cam, with the post engaging the cam at around 80° of flexion and thereafter acting like a load bearing surface in deep flexion.

The articulating surface of the post is convex & the cam is concave thus allowing a more congruent surface for allowing load transfer & the rotation to occur as the post does not impinge on the side walls of the box during rotations. This rotational freedom is necessary to prevent wear of the post hence loosening and osteolysis of the tibial component

A third joint was designed between the post & the cam, with the post engaging the cam at around 80° of flexion and thereafter acting like a load bearing surface in deep flexion.

The articulating surface of the post is convex & the cam is concave thus allowing a more congruent surface for allowing load transfer & the rotation to occur as the post does not impinge on the side walls of the box during rotations. This rotational freedom is necessary to prevent wear of the post hence loosening and osteolysis of the tibial component

**Mikulak et al., Loosening & osteolysis with the PFC , PC-substituting total knee replacement .JBJS 2001; 83A

**Mikulak et al., Loosening & osteolysis with the PFC , PC-substituting total knee replacement .JBJS 2001; 83A

The bar of the cam articulates with the post at a lower level, the jumping distance is increased to 16 mm, another feature to assist in enhanced stability.

1) The posterior edges of the tibial PE insert are chamfered to avoid impingement in deep knee flexion.

2) An anterior cutout in the tibial PE insert to accommodate the patellar tendon deep flexion

The tibia is monoblock & hence backside wear is reduced to a minimum, tibial PE insert has a deep dish design to prevent point loading poly wear.

In the INDUS design, the femoral box is designed so as to cut minimal bone there by incorporating the bone sparing principle.


Jumping Dist. – Edges – Tibia Monoblock – Small Femoral Box


Jumping Dist. – Edges – Tibia Monoblock – Small Femoral Box

A thorough anatomic study of the Indian knee joints The components being in sizes that are more suited to the Indian population.

The various sizes were designed in accordance with the suggestions of Vaidhya et al.** and by analyses of 100 computerized tomography scans in 50 patients (independent unpublished data)

** Vaidya , Ranawat Anthropometric measurements to design total knee prostheses for the Indian population. J Arthroplasty. 2000;15:79–85

Anatomic studiesAnatomic studies Suitable sizes for Indian population Suitable sizes for Indian population Indus Knee

Anatomic studiesAnatomic studies Suitable sizes for Indian population Suitable sizes for Indian population Indus Knee

The patella is a single peg anatomic design

The femoral components are separate for the right & left e deep Troch groove, open box for SC Nailing in case of Preprosthetic fracture

The INDUS knee is designed to be a high-flexion, Bone sparing and anatomic design suitable for the native population.

The prosthesis is Gamma irradiated in vacuum to increase the longevity of the polyethylene.

Design rationale of Indus Knee In conclusion

Design rationale of Indus Knee In conclusion

Alignment

Balancing

Correct Bony cuts, Component sizes, Cementation

Deformity correction (incl Patellar Tracking)

Sizing of components



X – rays - TemplatingImportant

Is there a need for Long leg radiographs in every TKR A Study – Pre Op Hip to Ankle Radiographs in TKA CORR 2004,404

McGrory et al A randomised prospective study 124 cases

No statistical difference

Long Leg radiographs definite Indicated Varus > 15° Valgus Pre existing Femoral / Tibial Deformity Very Short/ tall / Obese patients

Short Radiographs TEMPLATING

STANDARD Short X rays- Mech axis lacking

AP standing ( 14’’ X 17’’ film) CUTS PLANNED

Lateral View Best available data

Patellar Skyline View Certain assumptions

Pelvis with both Hip Joins

Successful TKA

Assessing the Results of Total Knee Replacement:

PainFunctionRange of MotionStabilityDeformity

Successful TKA

Successful TKA

• Benefits to balancing the ligaments: – Optimize the results,– Recognize potential errors in bone resection and

soft tissue problems intraoperatively

• Unbalanced knee– Stiff, loose painful– Premature wear– Early revision

• It is essential to balance the ligaments if one is to use a mobile bearing knee

Ligament Balancing

Ligament Balancing

• Varus, • Valgus, • Rotation, • Translation, • Flexion, • Extension, • Proximal, • Distal

“If we combine all of the possible malalignments we will note there are 11,684 methods to get it wrong and only one will have

perfect alignment……Lotke”

Bony Alignment

Bony Alignment

Goals

Confirm Tibial Cut Neutral

MCL = LCL

Flexion Gap = Extension Gap

Goals

Goals

• Tibial Resection

• Distal Femur Resection

• Femoral Antero-posterior Resection

• Ligament Balancing

• Femoral Finishing Cuts

Steps in TKA

Steps in TKA

Check Flexion Space

Check Extension Space

Check Alignment Of Tibial Cut

Resolve Discrepancies

Ligament Balancing Steps

Ligament Balancing Steps

Our study Material & Methods, Results &

conclusions

Our study Material & Methods, Results &

conclusions

To study a consecutive series of 18 pt’s ( 20 Knees) who had INDUS Knee prosthesis and evaluate and analyse the follow up results in short term ( 3-8 months- Ave 6 months)

Discuss the suitability of the High flex knee designs ( INDUS Knee) for Asian patients

PurposePurpose

Twenty primary total knee arthroplasties in 18 patients using the INDUS knee prosthesis were prospectively enrolled in this study and were performed from August 2011 to February 2012, at Govt Gen Hospital, Kakinada.

We have followed of all 20 patients at first 6weeks, then 3 and 6 months.

None had any serious complications, though we had 3 cases of swollen legs with no evidence of DVT(Doppler)

Materials and MethodsMaterials and Methods


There were 12 men (13 knees) and 6 (7 knees) women with a mean age of 62 yr ( range 52-72).

Two cases of bilateral TKR spaced at an average interval of 3 months

16 knees had OA, 4 Knees had rheumatoid arthritis.

Average Follow up of these 20 cases 6 months(3-8) and at each follow up visit we have assessed the clinical parameters, incl. the Knee Society scores, ROM, and

complications were recorded.

DermographicsDermographics




All are Thro Med P P App.&

All are Cemented

Methods Patella Resurfacinguni in 90% Patelloplasty done in 90% ( 18 of 20) Staged Bil in 10% Patella Resurfaced in 10%

An anterior midline incision, medial Parapatellar approach been used in all 20 cases. A combination of both measured resection and Gap balancing techniques been used for appropriate soft tissue balancing. All the components were cemented after pulsed lavage.

Patelloplasty (peripatellar synovectomy, electrocautery of the patellar rim, and removal of osteophytes) rather than patellar resurfacing was performed in 18 knees when the articular cartilage was found to be healthy and Patellar tracking is satisfactory and only in 2 cases Patellar resurfacing done.

Materials and MethodsMaterials and Methods Operative procedure

Materials and MethodsMaterials and Methods Operative procedure

Prophylactic antibiotics were given 30- 60 min before surgery. Intravenous antibiotics were continued for 10 days after surgery. Only in 3 cases we have made the patients to wear compression stockings for 12 weeks because of their excessive risk of DVT.

A drain was used for 48 h. Active quadriceps-strengthening exercises and range of motion were commenced within 2 post-operative days and weight bearing was allowed from the second to third post-operative day. These was not any formal Physiotherapy, only surgeon guided and patient self motivated, but still could achive 90° within 4-6 days in 90% of patients.


Operative procedure


Operative procedure

The patients were reviewed at 6 weeks, 3 months, 6 months and few at 8 months. Clinical parameters, including the Knee Society scores (KSS),** range of motion, post-operative clinical anterior knee pain and complications were recorded.

The KSS was evaluated in two parts: first, the knee score involving the clinical knee findings, and, second, the function score analyzes functional mobility of the patient.

In addition, patients were asked to squat or sit cross-legged at follow-up. Pre-operative factors affecting the post-operative ROM were also analyzed, including flexion contracture, deformity, and ROM. No subjective parameter was recorded.

***Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–4

Follow up and ResultsFollow up and Results

Follow up and ResultsFollow up and Results

Knee society score :

Knee society score …contd.

Pre& Post OP radiographs incl AP &lateral were assessed for

limb alignment, component positioning, and Loosening - any evidence of radiolucent

lines at the bone cement interface.

Statistical comparisons for such

a small number of cases is not very relevant. We found greatly improved postoperative clinical scores compared to preoperative clinical scores.

ResultsResults

ResultsResults

At ave.Follow up of 6 months (3–6), the mean knee score and the mean

function score were significantly improved from a pre-operative value of 40 points and 47 points to a post-operative value of 87 points and 86 points, respectively (P value <0.05).

Of 20 knees, 14 knees had flexion above 120°-130°

A total of 14 patients (14 knees, 70 %) could squat or sit cross-legged at

the final follow-up.

ResultsResults

Average Follow Up 6 MonthsAverage Follow Up 6 Months

ResultsResults

Average Follow Up 6 MonthsAverage Follow Up 6 Months

Of the 18 patients (20 knees),

14 knees had flexion > 120°,

4 had a flexion range of 100–110°, and

2 had a flexion range of 90–100°

with the mean range of movement being 115°.

a total of 14 patients (14 knees70 %) could squat or sit cross-legged at the final follow-up.

ResultsResults

Flexion Range-ROMFlexion Range-ROM

ResultsResults

Flexion Range-ROMFlexion Range-ROM

The mean tibiofemoral angle was 10.5°±3.9° of varus pre OP and 5.4°±2.2° of valgus (3–7° of valgus) at the final follow-up, with no loss of alignment noted in case.

No case for revision for early or late infection nor had any periprosthetic fracture.

ResultsResults Mean tibiofemoral angle changed to 5.4 valgus Post Op cf with 10.5

varus Pre Op

ResultsResults Mean tibiofemoral angle changed to 5.4 valgus Post Op cf with 10.5

varus Pre Op

Pre OpPre Op

Post OpPost OpA

Pre OpPre Op

Post OpPost OpA

At the last follow-up, the clinical anterior knee pain scores were

grade 0 (no pain) in 14 knees (70%),

grade 1 (mild pain) in 5 knees (25%), and

grade 2 (moderate pain) in 1 knee (5%);

none were grade 3 (severe pain).

ResultsResultsClinical Anterior Knee Pain ScoreClinical Anterior Knee Pain Score

ResultsResultsClinical Anterior Knee Pain ScoreClinical Anterior Knee Pain Score

Pre-op, the mean flexion contracture was 13.3° (range, 10–30°), the mean maximum flexion was 114.83° (60–120°), and the mean ROM was 106.2° (45–120°).

At the last follow-up, the mean flexion contracture was 3.19° (0–10°), and the mean ROM was 115° (90–130°).

These outcomes represent a satisfactory and significant improvement of ROM and movement were retained over time.

No clunks / crepitus were heard

Results - Results - Pre & Post Op ROMPre & Post Op ROM

Results - Results - Pre & Post Op ROMPre & Post Op ROM

Pre Op Post OpA severe Varus def > 12-15° Excellent Correction Valgus-3- 5°

Pre Op Post OpA severe Varus def > 15-20° Excellent Correction Valgus-3- 5°

Post Op - Excellent Flexion and ROM°

There was no mortality in the series

5 cases minor Anterior Knee Pain ( 25%)

3 cases of Swollen Legs but no DVT ( 15%)

4 cases of Minor Fixed Flexion Deformity( 20%)

COMPLICATIONSCOMPLICATIONS

COMPLICATIONSCOMPLICATIONS

Component sizing & proper components placement

is the key to the success of knee arthroplasty.**

Component oversizing in the AP dim. alters the delicate balance in F/E gap, resulting in flexion tightness Post Op because of increased tension in the quadriceps mechanism@ whereas oversizing in the mediolateral dim. affects the patellar tracking and wound closure.*

The risk of component oversizing with the other available implants is esp. present in Indians & other Asian subpopulations that are known to have a smaller build and stature as compared with the western population.

INDUS knee is based on careful assessment of anthropometric data from the Indian patients thus reducing the risk of oversizing.

**Goldberg et al., Technical consideration in total knee surgery: Management of patellar problems. OCNA. 1989;20:189 : @Ranawat CS. The patellofemoral joint in total condylar knee arthroplasty: Clin Orthop Relat Res. 1986;205:93–9

*Krackow KA. The technique of total knee arthroplasty. St Louis: CV Mosby; 1990.

DiscussionAchieving maximal knee flexion improves the patient satisfaction & knee performance.,but conventional knee arthroplasty before highflex designs rarely allows for knee flexion beyond 120°

The newer high-flexion knee replacement prostheses have reported a higher flexion achieved post-operatively, within a range of 130–135° of flexion.4

DiscussionAchieving maximal knee flexion improves the patient satisfaction & knee performance.,but conventional knee arthroplasty before highflex designs rarely allows for knee flexion beyond 120°

The newer high-flexion knee replacement prostheses have reported a higher flexion achieved post-operatively, within a range of 130–135° of flexion.4

Han et al.** reported a high incidence of loosening of the femoral component in a retrospective series of 72 knees using the Legacy posterior stabilized–flex TKR. At a mean follow-up of 32 months, aseptic loosening of the femoral component was found

in 27 (38%) cases, with 15 (21%) requiring revision at a mean of 23 months.

They concluded that the high rate of loosening was associated with weight bearing at

maximum flexion and inadequate support of the posterior condyle of the prosthesis.

In the INDUS knee, the modified post and cam functions as a load-bearing third joint & lend support to the posterior condyles during deep flexion. Our follow-up is short, but

still have had no cases of mechanical loosening of either of the components.

**Han et al., High incidence of loosening of the femoral component in legacy posterior stabilised-flex total knee replacement. J Bone Joint Surg Br. 2007;89:1457–61

DiscussionA number of modifications have been made in the post & cam mechanism of the

INDUS knee to enhance flexion and increase stability in deep flexion

DiscussionA number of modifications have been made in the post & cam mechanism of the

INDUS knee to enhance flexion and increase stability in deep flexion

For conventional implants, the range of movement following TKRs is reported to be approximately 110°10–16 and few patients can flex beyond 120°.41–43 The excellent ROM observed in this study is consistent with the kinematic advantages of high-flexion implants demonstrated in several biomechanical studies.17,18,31–34

The introduction of high-flexion prosthesis has raised concerns that the increased flexion which enables patients to squat or sit cross-legged may compromise the long-term results.19

There is also concern regarding loosening of the implant caused by design modifications requiring removal of more bone from the posterior femoral condyles and the intercondylar area.19

,44

However, our study shows favorable results, with mean values of 115° flexion and excellent total and function KSS.

No revisions for aseptic loosening were required. There were no incidents of instability or dislocation in the deep flexion.

DiscussionDiscussion

Sum up the DiscussionSum up the Discussion

Sum up the DiscussionSum up the Discussion

Max K/B Pt satsfaction & Good performance

Hence Hiflex Knees expected to do well Asian knees are developed to suit the correct

sizes as well as to fulfil the demand of Hiflexion Design modf of Indus are mainly 3 1) Increased J curve

2) Incresed Tib slope ( 7 ° cf 3 °)

3) Post & Cam act as 3rd Condyle Joint

Strengths of this study are Single Type of Prosthesis, single Hospital, same set up, same surgical technique and similar surgeons,

but weaknesses are limited number and shorter follow up.

However, the prospective nature of our study allows us to follow these patients and we should be able to identify and correct any problems seen with this new design.

We have so far 100% follow-up and we will report on medium and longer term results as they become available


In the present series, total knee arthroplasty with the INDUS knee prosthesis resulted in an excellent range of motion and good functional outcome, and the durability of the prosthesis is promising.


We conclude we have found the solution (for our most needy arthritic patients who are not so rich) ie., INDUS Knee prosthesis

I – Indigenious, Indian D – Durable, Dependable E – Efficient, Economical A – Affordable, Asian L – Long Lasting All in all it’s a NEW ‘IDEA’/ IDEAL Knee

ConclusionConclusion

References 1. Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring

system. Clin Orthop Relat Res. 1989;248:9–12.[PubMed: 2805502] 2. Insall J, Scott WN, Ranawat CS. The total condylar knee prosthesis: A report of two hundred

and twenty cases. J Bone Joint Surg Am. 1979;61:173–80.[PubMed: 422602] 3. Insall JN, Ranawat CS, Aglietti P, Shine J. A comparison of four models of total knee-

replacement prostheses. J Bone Joint Surg Am. 1976;58:754–65.[PubMed: 956219] 4. Insall J, Ranawat CS, Scott WN, Walker P. Total condylar knee replacement: Preliminary report

1976. Clin Orthop Relat Res. 2001;388:3–6.[PubMed: 11451129] 5. Ranawat CS. The patellofemoral joint in total condylar knee arthroplasty: Pros and cons based

on five- to ten-year follow-up observations. Clin Orthop Relat Res. 1986;205:93–9.[PubMed: 3698397]

6. Ranawat CS, Boachie-Adjei O. Survivorship analysis and results of total condylar knee arthroplasty: Eight- to 11-year follow-up period. Clin Orthop Relat Res. 1988;226:6–13.[PubMed: 3335108]

7. Ranawat CS, Rose HA. Clinical and radiographic results of total-condylar knee arthroplasty: A 3- to 8-year follow-up. In: Ranawat CS, editor. In Total- Condylar Knee Arthroplasty: Techniques, Results, and Complications. New York: Springer; 1985. pp. 140–8.

8. Rowe PJ, Myles CM, Walker C, Nutton R. Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: How much knee motion is sufficient for normal daily life? Gait Posture. 2000;12:143–55.[PubMed: 10998612]

9. Mulholland SJ, Wyss UP. Activities of daily living in non-Western cultures: Range of motion requirements for hip and knee joint implants. Int J Rehabil Res. 2001;24:191–8

References 10. Insall JN, Lachiewicz PF, Burstein AH. The posterior stabilized condylar prosthesis: A

modification of the total condylar design: Two to four-year clinical experience. J Bone Joint Surg Am. 1982;64:1317–23.[PubMed: 7142239]

11. Maloney WJ, Schurman DJ. The effects of implant design on range of motion after total knee arthroplasty: Total condylar versus posterior stabilized total condylar designs. Clin Orthop Relat Res. 1992;278:147–52.[PubMed: 1563146]

12. Ranawat CS, Luessenhop CP, Rodriguez JA. The press-fit condylar modular total knee system: Four-to-six-year results with a posterior-cruciate-substituting design. J Bone Joint Surg Am. 1997;79:342–8.[PubMed: 9070521]

13. Scott WN, Rubinstein M, Scuderi GJ. Results after knee replacement with a posterior cruciate-substituting prosthesis. J Bone Joint Surg Am. 1988;70:1163–73.[PubMed: 3417701]

14. Stern SH, Insall JN. Posterior stabilized prosthesis: Results after follow-up of nine to twelve years. J Bone Joint Surg Am. 1992;74:980–6.[PubMed: 1522105]

15. Martin SD, McManus JL, Scott RD, Thornhill TS. Press-fit condylar total knee arthroplasty: 5- to 9-year follow-up evaluation. J Arthroplasty. 1997;12:603–14.[PubMed: 9306210]

16. Ritter MA, Campbell E, Faris PM, Keating EM. Long-term survival analysis of the posterior cruciate condylar total knee arthroplasty: A 10-year evaluation. J Arthroplasty. 1989;4:293–6.[PubMed: 2621461]

17. Argenson JN, Komistek RD, Mahfouz M, Walker SA, Aubaniac JM, Dennis DA. A high flexion total knee arthroplasty design replicates healthy knee motion. Clin Orthop Relat Res. 2004;428:174–9.[PubMed: 15534540]

18. Li G, Most E, Sultan PG, Schule S, Zayontz S, Park SE, et al. Knee kinematics with a high-flexion posterior stabilized total knee prosthesis: An in vitro robotic experimental investigation. J Bone Joint Surg Am. 2004;86:1721–9.[PubMed: 15292421]

.[PubMed: 15824934]

References 19. Ranawat CS. Design may be counterproductive for optimizing flexion after TKR. Clin Orthop Relat

Res. 2003;416:174–6.[PubMed: 14646758] 20. Conditt MA, Thompson MT, Usrey MM, Ismaily SK, Noble PC. Backside wear of polyethylene tibial

inserts: Mechanism and magnitude of material loss. J Bone Joint Surg Am. 2005;87:326–31.[PubMed: 15687155]

21. Vaidya SV, Ranawat CS, Aroojis A, Laud NS. Anthropometric measurements to design total knee prostheses for the Indian population. J Arthroplasty. 2000;15:79–85.[PubMed: 10654467]

22. Bellemans J, Robijns F, Duerinckx J, Banks S, Vandenneucker H. The influence of tibial slope on maximal flexion after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2005;13:193–6

23. Mikulak SA, Mahoney OM, dela Rosa MA, Schmalzried TP. Loosening and osteolysis with the press-fit condylar posterior-cruciate-substituting total knee replacement. J Bone Joint Surg Am. 2001;83:398–403.[PubMed: 11263644]

24. Vince KG. Principles of condylar knee arthroplasty: Issues evolving. Instr Course Lect. 1993;42:315–24.[PubMed: 8463681]

25. Beight JL, Yao B, Hozack WJ, Hearn SL, Booth RE., Jr The patellar “clunk” syndrome after posterior stabilized total knee arthroplasty. Clin Orthop Relat Res. 1994;299:139–42.[PubMed: 8119008]

26. Hozack WJ, Rothman RH, Booth RE, Jr, Balderston RA. The patellar clunk syndrome: A complication of posterior stabilized total knee arthroplasty. Clin Orthop Relat Res. 1989;241:203–8.[PubMed: 2924465]

27. Collier MB, Engh CA, Jr, McAuley JP, Ginn SD, Engh GA. Osteolysis after total knee arthroplasty: Influence of tibial baseplate surface finish and sterilization of polyethylene insert: Findings at five to ten years postoperatively. J Bone Joint Surg Am. 2005;87:2702–8.[PubMed: 16322620]

References 28. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop

Relat Res. 1989;248:13–4.[PubMed: 2805470] 29. Ranawat AS, Rossi R, Loreti I, Rasquinha VJ, Rodriguez JA, Ranawat CS. Comparison of the PFC Sigma

fixed-bearing and rotating-platform total knee arthroplasty in the same patient: Short-term results. J Arthroplasty. 2004;19:35–9.[PubMed: 14716648]

30. Ranawat CS, Flynn WF, Jr, Deshmukh RG. Impact of modern technique on long-term results of total condylar knee arthroplasty. Clin Orthop Relat Res. 1994;309:131–5.[PubMed: 7994951]

31. Gandhi R, Tso P, Davey JR, Mahomed NN. High-flexion implants in primary total knee arthroplasty: A meta-analysis. Knee. 2009;16:14–7.[PubMed: 18786829]

32. Kim YH, Choi Y, Kwon OR, Kim JS. Functional outcome and range of motion of high-flexion posterior cruciate-retaining and high-flexion posterior cruciate-substituting total knee prostheses: A prospective, randomized study. J Bone Joint Surg Am. 2009;91:753–60.[PubMed: 19339558]

33. Gupta SK, Ranawat AS, Shah V, Zikria BA, Zikria JF, Ranawat CS. The PFC Sigma RP-F TKA designed for improved performance: A matched-pair study. Orthopedics. 2006;29:S49–52.[PubMed: 17002149]

34. Bin SI, Nam TS. Early results of high-flex total knee arthroplasty: Comparison study at 1 year after surgery. Knee Surg Sports Traumatol Arthrosc. 2007;15:350–5.[PubMed: 17072657]

35. Goldberg VM, Figgie HE, 3rd, Figgie MP. Technical consideration in total knee surgery: Management of patellar problems. Orthop Clin North Am. 1989;20:189.[PubMed: 2646562]

36. Ranawat CS. The patellofemoral joint in total condylar knee arthroplasty: Pros and cons based on five- to ten-year follow-up observations. Clin Orthop Relat Res. 1986;205:93–9.[PubMed: 3698397]

37. Krackow KA. The technique of total knee arthroplasty. St Louis: CV Mosby; 1990. 38. Hoaglund FT, Low WD. Anatomy of the femoral neck and head, with comparative data from Caucasians

and Hong Kong Chinese. Clin Orthop Relat Res. 1980;152:10–6.[PubMed 39. Saikia KC, Bhuyan SK, Rongphar R. Anthropometric study of the hip joint in Northeastern region

References 40. Han HS, Kang SB, Yoon KS. High incidence of loosening of the femoral

component in legacy posterior stabilised-flex total knee replacement. J Bone Joint Surg Br. 2007;89:1457–61.[PubMed: 17998181]

41. Anouchi YS, McShane M, Kelly F, Jr, Elting J, Stiehl J. Range of motion in total knee replacement. Clin Orthop Relat Res. 1996;331:87–92.[PubMed: 8895623]

42. Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A. Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty: Influence of posterior condylar offset. J Bone Joint Surg Br. 2002;84:50–3.[PubMed: 11837832]

43. Dennis DA, Komistek RD, Colwell CE, Jr, Ranawat CS, Scott RD, Thornhill TS, et al. In vivo anteroposterior femorotibial translation of total knee arthroplasty: A multicenter analysis. Clin Orthop Relat Res. 1998;356:47–57.[PubMed: 9917667]

44. Ritter MA. High-flexion knee designs: More hype than hope? In the affirmative. J Arthroplasty. 2006;21:40–1.[PubMed: 16781427]

Indian J Orthop. 2009 Oct-Dec; 43(4): 367–374. The INDUS knee prosthesis – Prospective multicentric trial of a posteriorly

stabilized high-flex design: 2 years follow-up Kantilal H Sancheti, Nandu S Laud, Gurava Reddy, et al

Dedicated to all those who could understand the suffering of poor arthritic patient, like we do at GGH

(hopefully you all will join hands with us to help those in the near future)

Thanking You

Documents

Sto Indus Knee 2