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Knee Replacement

People suffering from knee injuries and joint pain may undergo knee replacement, a surgery involving an artificial implant. Patients receive either a total or partial knee replacement and the types of materials and fixation techniques may vary.

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Knee replacement surgery, also called arthroplasty, is a surgical procedure to resurface a damaged knee that is painful or no longer stable.  Similar to hip surgery, there are alternative approaches that can be taken to help with the pain and joint stiffness.  Discuss with your doctor different options that may help to reduce the pain and decide on what options and course of therapy is right for you.

Knee Replacement Alternatives

Before proceeding with surgery you may determine that one of the following alternatives to knee replacement surgery may be helpful:

  • Pain medication such as Ibuprofen or aspirin to help with the inflammation in the joint
  • Physical therapy under the supervision of a licensed physical therapist along with your doctors direction will help with mobility of the joint
  • Use of an aid such as a cane or walker may become necessary to move around to allow reduction of the swelling and relieve stress on the joint.
  • Steroid injection at the site to help pain and reduce the inflammation
  • Losing weight for overweight patients will help to reduce the pressure and stress on the joint.

When conventional approaches like physical therapy do not work or they are not enough to reduce the pain in the joint, hip resurfacing or hip replacement (also known as hip arthroplasty) is an option.

Knee Pain

The knee joint is the largest joint in the body and sometimes simply referred to as a hinge joint similar to the elbow where motion occurs in only one direction.  The knee joint, however, consists of a complex system of bones, ligaments, tendons, and cartilage and can handle more complex movements having a rotational component.

The knee joint consists of three bones.  The lower part of the femur (or the thigh bone), the larger of the two bones in the lower leg called the tibia or shinbone, and the patella (the bone that floats in front of the knee more commonly known as the kneecap).

The ends of each of the bones involved in the knee joint along with the back side of the patella are covered with a layer of articular cartilage; a smooth substance that protects the surface of the bones and allows the bones to move or glide in more easily. Over time, normal wear and tear on the cartilage, traumatic injury, or possibly disease can lead to loss or damage of the cartilage coating.  The Loss of cartilage and the continued bone on bone contact is the process of osteoarthritis.

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The anterior and posterior “cruciate” ligaments are so called due to their position and the cross-like shape they form within the knee.

Between the femur and the tibia are two c-shaped structures that act as shock absorbers for the joint called meniscus that help to stabilize the joint and act as a cushion.  The joint is further stabilized by 4 major ligaments;  The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) located in the center of the knee stabilize the movement of the knee front to back while the medial collateral ligament (MCL) and the lateral collateral ligaments located on either side of the knee stabilize the side to side movement.

The remaining surfaces within the knee joint are covered with a thin lining called the synovial membrane that contains a fluid that lubricates the joint further reducing frication and wear to the joint.

Knee Replacement Techniques

Each type of knee implant has advantages and disadvantages some of the options include:

  • Total vs. Partial Knee Replacement

  • Mobile vs. Fixed Bearing Surface

  • Cemented vs. Noncemented

  • Cruciate Retaining vs. Posterior Stabilized Implants

Types of Devices for Knee Replacement

When deciding on the type of implant a patient will receive, there are many different issues your surgeon will consider before deciding on a particular prosthesis or replacement device. Some of the factors include gender, 1 the knee itself (the extent of the injury and state of the knee at the time of the surgery), age of the patient (levels of activity to be expected and the ability to recover), and also the choice of implants that are available to them. 2 Despite the number of choices, cost of the implant, types of insurance carriers, and the hospital can influence the surgeon’s decision.  It is important to discuss these things with your doctor before moving forward.

Each type of knee implant has advantages and disadvantages some of the options include:

Total vs. Partial Knee Replacement

In some cases some of the bone of can be spared in the process retaining some of the natural biomechanics.

Choices in type of bearing surface: The replacement features of the ends of the bone are typically made of a metal (usually cobalt chrome or titanium), however there are options the surgeon can choose from for the interface where the ends of the bones meet.

Understandably an ideal bearing surface: 3

  • has a low co-efficient of friction.
  • is resistant to third-body damage and wear.
  • generates small amounts of wear debris.
  • causes low cellular reactions to such wear debris.

Typically these surfaces are made of polyethylene, metal, ceramic, or a metal-ceramic hybrid.

Mobile vs. Fixed Bearing Surface

There is an option to incorporate a mobile bearing surface, but due to the potential slippage of the implant, most often the choice of having a fixed bearing surface is used.

Cemented vs. Noncemented

Similar to hip replacement surgeries, the surgeon has the choice of using cement to fix the implant in place. All early knee replacement surgeries used cement to secure the implant to end of the bone because of the mechanical stress in this area and speed in fixation. The cement is more like a grout and similarly can break down over time. One advantage is that strength of the implant is at its greatest just after the surgery. Also, antibiotics can be mixed into the cement in order to fight infection, one of the most severe complications of knee replacement surgery which can lead to revision surgery. 4

Like the case in hip replacements, noncemented devices in knee replacements are “press-fit” and the bone eventually grows into the device. Although it has proved successful with hip implants, more often cemented components are used because there appears to be no significant improvement in the success of the device after 15 years and the cementless components are potentially more expensive. 5

Cruciate Retaining vs. Posterior Stabilized Implants

The cruciate ligaments stabilize the front to back movement of the knee joint. In most cases, the anterior cruciate ligament (ACL) is torn or no longer useful and the posterior cruciate ligament (PCL), in some cases, remains intact. It appears inconclusive whether one design is superior to the other based on one study and remains the choice of the surgeon based on preference and the condition of the PCL at the time of the surgery

  1. American Academy of Orthopaedic Surgeons, Technology Overview: Gender Specific Knee Replacements, Board Approved: December 8, 2007, available at: http://www.aaos.org/research/overviews/gsk.pdf, accessed on: September 4, 2013 

  2. Orthopaedics New England, Knee Replacement Prosthesis Designs, Copyright 2008, available at: http://www.keggiorthosurgery.com/Revision_Hip_And_Knee_Surgery.php, accessed on: September 4, 2013 

  3. Patel S, Hossain FS, Haddad FS, “Focus On… Bearing surfaces in lower limb total joint arthroplasty”, The British Editorial Society of Bone & Joint Surgery [internet]. May 2010, available at: http://www.boneandjoint.org.uk/content/focus/bearing-surfaces-lower-limb-total-joint-arthroplasty, accessed on: September 4, 2013. 

  4. Moran E, Byren I, Atkins BL. The diagnosis and management of prosthetic joint infections. J Antimicrob Chemother. 2010 Nov;65 Suppl 3:iii45-54. 

  5. Baker PN, Khaw FM, Kirk LM, Esler CN, Gregg PJ. A randomised controlled trial of cemented versus cementless press-fit condylar total knee replacement: 15-year survival analysis. J Bone Joint Surg Br. 2007 Dec;89(12):1608-14. PubMed PMID:18057361.