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C OPYRIGHT Ó 2020 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Comparison of Joint Perception Between

Posterior-Stabilized and Ultracongruent Total
Knee Arthroplasty in the Same Patient
Man Soo Kim, MD, PhD, In Jun Koh, MD, PhD, Chul Kyu Kim, MD, Keun Young Choi, MD, Jin Hwa Jeon, MD, and
Yong In, MD, PhD

Investigation performed at Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

Background: Posterior-stabilized and ultracongruent designs are 2 common examples of posterior cruciate ligament-
substituting total knee arthroplasty (TKA) prostheses. There is a lack of evidence regarding joint perception differences
between ultracongruent and posterior-stabilized TKA. The purpose of this study was to compare the postoperative knee
stability, function, and joint perception between ultracongruent and posterior-stabilized TKA in the same patients in order
to determine whether there was a difference based on design.
Methods: This prospective, randomized controlled trial included 50 patients who underwent same-day bilateral TKA
utilizing Persona (Zimmer Biomet) posterior-stabilized implants in 1 knee (posterior-stabilized group) and ultracongruent
implants in the other knee (ultracongruent group). At 2 years postoperatively, patients were evaluated for knee stability,
function, and joint perception. Postoperative static knee anteroposterior stability and femoral rollback were compared.
Knee function was evaluated with use of the Knee Society Score and Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC). Joint perception was compared by evaluating noise generation, side preference, satis-
faction, and the Forgotten Joint Score.
Results: The ultracongruent group had more knee anteroposterior laxity (4.5 mm compared with 1.8 mm in the posterior-
stabilized group; p < 0.001) and less femoral rollback (4.2 mm compared with 9.0 mm in the posterior-stabilized group; p
< 0.001). Knee Society Score and WOMAC scores were not significantly different between groups (all p > 0.05). Although
the ultracongruent group showed less noise generation than the posterior-stabilized group (18% compared with 38%,
respectively; p = 0.026), there were no differences in side preference, satisfaction, or Forgotten Joint Score (all p > 0.05).
Conclusions: Both groups had similar joint perception 2 years postoperatively, with obvious differences in noise gen-
eration and more sagittal laxity with less femoral rollback in the ultracongruent group.
Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

T
he posterior-stabilized total knee arthroplasty (TKA)
has a cam-post mechanism that replaces the function of
the posterior cruciate ligament, which offers a repro-
ducible physiologic femoral rollback and an enhancement of
the range of motion of the knee1-3. However, this approach has
led to clinical problems, including distal femoral intercondylar
fracture as a result of the box cut4, patellar clunk syndrome5,6,
and noise generation6.
The posterior cruciate ligament-sacrificing ultracongruent
TKA design was introduced to overcome the limitations of the
cam-post posterior cruciate ligament-substituting TKA ap-
proach7. Ultracongruent TKA has anterior and posterior lips
with a curved tibial insert in the sagittal plane, which provides
high conformity and avoids anterior subluxation of the femoral
condyle during knee flexion7-9. Patient complaints stem from the
fact that TKA-indicated knees feel different from healthy ones
before the surgical procedure10. As a result, the patient percep-
tion of a distinct improvement in the diseased knee relative to the
healthy knee itself is important6,11-13. There have been some
comparative studies of ultracongruent and posterior-stabilized

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest
forms are provided with the online version of the article (http://links.lww.com/JBJS/G193).

A data-sharing statement is provided with the online version of the article (http://links.lww.com/JBJS/G244).

J Bone Joint Surg Am. 2021;103:44-52 d http://dx.doi.org/10.2106/JBJS.20.00279

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TKA, but to our knowledge, no studies to date have focused on
patient perception7-9,14. In addition, randomized controlled trials
assessing ultracongruent and posterior-stabilized TKA in the
same patient undergoing bilateral TKA are even more scarce7-9,14.
An important component of patient perception is joint
awareness; specifically, whether the patient can feel the TKA13.
Patient perception of noise generation could also be a key
factor6. In this study, we sought to investigate joint perception
as well as the knee stability and function of posterior-stabilized
and ultracongruent TKA in order to determine whether there
was a difference based on design. It was hypothesized that
ultracongruent TKA would show comparable knee stability,
function, and joint perception compared with posterior-
stabilized TKA.
Materials and Methods
T his prospective, randomized controlled trial included 50
patients (100 knees) undergoing TKA for primary osteo-
arthritis from December 2016 to November 2017. This study
received institutional review board approval. All eligible
patients were informed of the standardized clinical trial
information and provided written informed consent. The trial
was registered at ClinicalTrials.gov (NCT02992613). Please
note that although the present trial was prospectively registered
with ClinicalTrials.gov, changes were made to the study design
following registration; our initial registration was made prior to
the mandate by The Journal of Bone & Joint Surgery requiring
that the study design as listed on ClinicalTrials.gov match that
reported in the manuscript. At the time of registration, we had
considered the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC) to be the primary outcome;
however, following trial registration but before patient enroll-
ment, the primary outcome was changed to the Forgotten Joint
Score (FJS), and no changes were made to the ClinicalTrials.gov
registration. This change was made because we considered FJS
to better reflect differences in patient joint perception from
preoperatively to postoperatively. Patients who had a diagnosis
of inflammatory arthritis, posttraumatic arthritis, secondary
osteoarthritis, a flexion contracture of >20°, or a prior surgical
procedure in either knee, or who declined to participate in the
study, were excluded15. Before the surgical procedure, it was
confirmed that no patient had a hearing deficit and that no
patient had undergone arthroplasty in any other joint. All
patients underwent same-day bilateral TKA with use of the
Persona posterior-stabilized knee implant system (Zimmer
Biomet) in 1 knee and the Persona ultracongruent knee
implant system (Zimmer Biomet) in the other knee. A total of
52 patients were screened, and 2 of these patients were excluded
for declining to participate. Thus, 100 knees in 50 patients were
randomized to either the posterior-stabilized or ultracongruent
group. All patients completed a minimum of 2 years of follow-
up (Fig. 1).
In ultracongruent inserts, the anterior and posterior lip
heights are 6.50 and 4.0 mm, respectively, on the medial side
and 4.38 and 1.80 mm, respectively, on the lateral side. In
posterior-stabilized inserts, the anterior and posterior lip
C O M PA R I N G J O I N T P E R C E P T I O N W I T H P O S T E R I O R -S TA B I L I Z E D AND
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heights are 1.67 and 2.46 mm, respectively, on the medial side
and 3.01 and 1.12 mm, respectively, on the lateral side. Ran-
domization was performed with use of sealed envelopes con-
taining the prosthesis type (i.e., posterior-stabilized or
ultracongruent) that were opened in the operating room prior
to the start of the surgical procedure. The first knee received the
prosthesis indicated in the envelope and the other knee received
the other prosthesis. All surgical procedures were performed by
the senior author (Y.I.). All patients received anesthesia, and a
tourniquet was applied to the operative knee in all procedures.
Identical surgical techniques were utilized in the 2 groups. Both
cruciate ligaments were resected before bone cutting. The
cruciate-retaining femoral component and the ultracongruent
tibial insert were utilized in the ultracongruent group. In the
posterior-stabilized group, additional femoral box cutting was
essential. All components were cemented.
Postoperative follow-up evaluations were performed at
3 months, 6 months, and 1 year postoperatively, and annually
thereafter. The active range of motion of the knee was mea-
sured with use of a 60-cm goniometer with the patient in a
supine position. Lower-extremity alignment was measured
with use of the hip-knee-ankle angle. Anteroposterior stability
of the knee was evaluated with use of the Telos SD 900 Stress
Device (Telos Medical) with a force of 150 N applied to knees
flexed at 90° (Figs. 2-A through 2-D)16. Anteroposterior sta-
bility was defined as the distance between a line drawn along
the posterior border of the tibial component and a vertical line
at the posterior border of the femoral component. Antero-
posterior stability was calculated as the sum of anterior and
posterior laxity. Femoral rollback was also measured (Figs. 3-A
and 3-B)17. All measurements were based on DICOM (Digital
Imaging and Communications in Medicine) data, utilizing the
ruler and protractor functions provided by the PACS (Picture
Archiving and Communication System) function in M-View
(Marotech). Radiographic measurements were made every year
after the surgical procedure and were measured by 2 ortho-
paedic surgeons who did not participate in the procedures or
the research. All images were measured independently by 2
blinded orthopaedic surgeons. The average of the measure-
ments obtained by the 2 readers was used. The reproducibility
of the measurements was high, with an intraclass correlation
coefficient of 0.83 (p < 0.001).
Clinical functional outcomes were evaluated with use of
the Knee Society Score18 and WOMAC19. Joint perception was
evaluated using noise generation, side preference, satisfaction,
and the FJS20, which were checked by an independent blinded
assessor at 1 year postoperatively and then yearly thereafter. All
complications were recorded.
Noise generation was evaluated according to 5 ques-
tions6,21-23: (1) Do you hear noise? (2) Do you feel noise? (3) Is the
noise a concern, causing discomfort? (4) What kind of noise do
you hear or feel? (5) What part of the knee is involved? For the
first 3 questions, patients were also asked to score according to a
5-point integer scale: “never,” “rarely,” “sometimes,” “often,” and
“extremely often.”6 For the first and second questions, the
responses were categorized into 2 groups of “never or rarely” and
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Fig. 1
Consolidated Standards of Reporting Trials (CONSORT) flow diagram.
“sometimes, often, or extremely often.” For the third question,
the responses were divided into “never” and “rarely, sometimes,
often, or extremely often.” Possible answers to the fourth ques-
tion also consisted of 5 choices: “never,” “clunk,” “crepitus,”
“grinding,” and “clicking.”6,21-23 Finally, answers to the fifth
question consisted of “never,” “patella,” “joint,” “both,” and
“other.” A questionnaire for noise generation was provided to
each patient for each knee, and patients were asked to respond
according to their subjective judgment.
Side preferences expressed by patients were recorded
preoperatively and at the time of the latest follow-up. Patients
also rated their level of satisfaction with TKA with use of a 5-
point Likert scale.
The FJS is a well-validated scoring questionnaire with 12
questions indicated for the assessment of patient awareness of
the artificial joint during daily life activities postoperatively24.
Statistical Analysis
An a priori power analysis based on the results of a recent study
was performed25,26. Using the 2-sided hypothesis test at an alpha
level of 0.05 and a power of 80%, it was found that 39 knees in
each group were required to detect a difference of 14.5 points
on the FJS26 with a standard deviation of 22 points25. In total, we
recruited 50 patients (100 knees) to ensure that we would end
up with at least 39 patients, considering a 25% failure rate.
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Continuous variables were analyzed with use of the Student t
test or the Wilcoxon signed-rank test. The chi-square or Fisher
exact test was utilized to evaluate the significance of differences
in the categorical variables. Statistical analyses were performed
with use of SPSS (version 21.0 for Windows; IBM), and sig-
nificance was set at 0.05.
Results
T he study included 49 women and 1 man with a mean age of
68.2 years. The mean body mass index was 27.3 kg/m2. The
mean polyethylene insert thickness was 12.0 mm in the
posterior-stabilized and 13.2 mm in the ultracongruent groups
(p < 0.001). The hip-knee-ankle angle was changed from 9.5°
varus to 1.9° varus in the posterior-stabilized group and 10.1°
varus to 2.3° varus in the ultracongruent group. There were no
significant differences in the hip-knee-ankle angle between the
groups at the preoperative stage and at the 2-year postoperative
stage (all p > 0.05).
The anteroposterior stability demonstrated significantly
more sagittal laxity in the ultracongruent group (p < 0.001)
(Table I). Meanwhile, the femoral rollback in the full-flexion
position was significantly less in the ultracongruent group (4.2 mm)
than in the posterior-stabilized group (9.0 mm; p < 0.001).
There was no significant difference in range of motion
preoperatively or at 2 years postoperatively (p > 0.05) (Table II).
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Fig. 2-A Fig. 2-B

Fig. 2-C Fig. 2-D

Figs. 2-A through 2-D Radiographs showing static anteroposterior stability in posterior-stabilized and ultracongruent TKA. Anteroposterior stability
was defined as the distance between a line drawn along the posterior border of the tibia component and a vertical line at the posterior border of the
femoral component. Anteroposterior stability of the knee was evaluated by anterior and posterior translation of the tibia in relation to the femur by
anterior and posterior drawer stress radiographs at 90° of knee flexion using a force of 150 N with the Telos Stress Device. Stability mea-
surements were collected using the sum of the anterior and posterior displacements. Figs. 2-A and 2-B Anterior (Fig. 2-A) and posterior (Fig. 2-B)
stress radiographs of a posterior-stabilized TKA. Figs. 2-C and 2-D Anterior (Fig. 2-C) and posterior (Fig. 2-D) stress radiographs of an
ultracongruent TKA.

The postoperative range of motion was 4.4° greater than the (p > 0.05). There were no significant differences in the Knee
preoperative value in the ultracongruent group and 6.3° greater Society Score and WOMAC scores preoperatively or at 2 years
in the posterior-stabilized group, with no significant difference postoperatively (all p > 0.05) (Table II).

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Fig. 3-A
Figs. 3-A and 3-B Full-flexion lateral radiographs showing femoral rollback in a posterior-stabilized (Fig. 3-A) and an ultracongruent (Fig. 3-B) TKA. Femoral
rollback was measured as the distance from the sulcus point, the deepest point of the polyethylene insert, to the contact point of the femoral component
and the polyethylene insert on the full-flexion lateral radiograph of the knee.
The incidence of the patient hearing or feeling noise
generation was lower in the ultracongruent group (p = 0.026
and p = 0.041, respectively). However, the degree of discomfort
caused by the noise generation did not differ between the 2
groups (p > 0.05). In both groups, there was no significant
difference in concerns about noise generation (p > 0.05) (Table
III). The source of noise was similar between the 2 groups (p >
0.05) (Table III).
Additionally, there was no difference in the rate of side
preference and satisfaction (p > 0.05) (Table IV). The FJS
improved after TKA in both groups, and there was no signifi-
cant difference in the level of improvement (p > 0.05). The
average FJS at the time of the latest follow-up was also not
significantly different (p > 0.05) (Table V).
There were no major complications that required reop-
eration for any reason in either group during the follow-up
period.
TABLE I Knee Stability*
Posterior-Stabilized (N = 50)
Anterior displacement (mm) 5.4 ± 3.4
Posterior displacement (mm) 7.1 ± 3.1
Anteroposterior laxity (mm) 1.8 ± 2.8
Femoral rollback (mm) 9.0 ± 2.1
*Values are given as the mean and standard deviation.
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Fig. 3-B
Discussion
he most important finding of this study was that there was
T no difference in the FJS between posterior-stabilized and
ultracongruent TKA designs. The rate of noise generation was
significantly higher in posterior-stabilized TKA, but there was
no difference in the discomfort caused by noise generation
between the 2 groups.
To the best of our knowledge, this was the first randomized
controlled trial to study both posterior-stabilized and ultra-
congruent TKA in the same patient using the FJS as the primary
outcome measure. Although there were many other methods of
clinical evaluation, the FJS was included because it had a high-end
functionality including a low ceiling effect in patients with supe-
rior clinical features following arthroplasty13,24-27. In this study,
there was no difference in the FJS between posterior-stabilized and
ultracongruent TKA, and none of the detailed items of the FJS
questionnaire showed differences between the 2 groups.
Ultracongruent (N = 50) P Value
7.2 ± 2.7 0.010
11.7 ± 3.6 <0.001
4.5 ± 3.8 <0.001
4.2 ± 3.5 <0.001
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TABLE II Preoperative and Postoperative Functional Outcomes*

Preoperative 2 Years Postoperatively

Posterior-Stabilized Ultracongruent P Posterior-Stabilized Ultracongruent P
(N = 50) (N = 50) Value (N = 50) (N = 50) Value

FC (°) 4.6 ± 5.7 4.4 ± 4.7 0.849 0.7 ± 1.8 0.3 ± 1.2 0.186
Maximum flexion (°) 125.7 ± 10.6 126.4 ± 10.2 0.738 128.1 ± 5.9 126.8 ± 6.0 0.308
ROM (°) 121.1 ± 12.9 122.2 ± 11.9 0.658 127.4 ± 6.0 126.5 ± 6.0 0.496
KSS 130.9 ± 56.0 129.5 ± 56.4 0.915 159.7 ± 27.1 163.0 ± 22.6 0.869
Pain 15.7 ± 9.9 14.6 ± 10.2 0.644 51.2 ± 23.1 52.2 ± 22.9 0.947
Function 115.0 ± 55.4 114.7 ± 55.0 0.980 108.5 ± 27.0 110.8 ± 24.2 0.941
WOMAC 61.0 ± 12.6 63.2 ± 10.0 0.427 14.5 ± 12.6 14.3 ± 12.8 0.965
Pain 12.5 ± 3.8 13.2 ± 2.8 0.366 1.5 ± 2.0 1.4 ± 2.5 0.902
Stiffness 4.3 ± 1.8 4.7 ± 1.8 0.338 1.2 ± 1.3 1.1 ± 1.3 0.671
function 44.1 ± 8.9 45.3 ± 7.2 0.550 11.8 ± 10.5 11.8 ± 10.4 0.979

*Values are given as the mean and standard deviation. FC = flexion contracture, ROM = range of motion, and KSS = Knee Society Score.

Unmet patient expectations are the most important
factors to understand in determining postoperative satisfac-
tion12. Noise generation might cause problems on its own but
even if it did not actually cause functional problems, the
postoperative results still might not meet patient expectations.
Therefore, it was thought to be important to investigate noise
generation for each TKA implant type. Patient-perceived noise
generation following TKA is continually reported6,21,22. In par-
ticular, the perception of noise generation in posterior-
stabilized TKA, associated with patellar clunk syndrome, is

TABLE III Noise Generation*

Posterior-Stabilized (N = 50) Ultracongruent (N = 50) P Value

1. Do you hear noise? 0.026

Never/rarely 31 (62.0%) 41 (82.0%)
Sometimes/often/extremely often 19 (38.0%) 9 (18.0%)
2. Do you feel noise? 0.041
Never/rarely 25 (50.0%) 35 (70.0%)
Sometimes/often/extremely often 25 (50.0%) 15 (30.0%)
3. Is the noise a concern, causing discomfort? 0.799
Never 40 (80.0%) 41 (82.0%)
Rarely/sometimes/often/extremely often 10 (20.0%) 9 (18.0%)
4. What kind of noise you hear or feel? 0.102
None 19 (38.0%) 32 (64.0%)
Clunk 5 (10.0%) 5 (10.0%)
Crepitus 8 (16.0%) 4 (8.0%)
Grinding 7 (14.0%) 3 (6.0%)
Clicking 11 (22.0%) 6 (12.0%)
5. What part of the knee is involved? 0.076
None 19 (38.0%) 32 (64.0%)
Patella 15 (30.0%) 8 (16.0%)
Joint 14 (28.0%) 9 (18.0%)
Both 2 (4.0%) 1 (2.0%)

*Values are given as counts and percentages.

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of various companies could be adjusted for. In this study, the

TABLE IV Postoperative Side Preference and Satisfaction*
perception of noise generation from each implant was evalu-
2 Years Postoperatively ated in the same patient, and there was a significant difference
between the posterior-stabilized (38%) and ultracongruent
Posterior-Stabilized Ultracongruent P
(N = 50) (N = 50) Value
(18%) implants.
In the case of noise generation, the noise may be heard
Side preference 25 (50%) 22 (44%) 0.826 and felt21. Therefore, this study investigated both hearing and
Satisfaction 0.493 feeling of noise generation. Hearing noise generation was de-
Very satisfied 36 (72%) 38 (76%) noted when another person heard the noise directly. We also
Satisfied 14 (28%) 11 (22%) investigated the type of noise and the location of noise gener-
Neutral 0 (0%) 1 (2%) ation at the knee. Both hearing and feeling noise showed sig-
Dissatisfied 0 (0%) 0 (0%)
nificant differences between the 2 groups23. Clicking was the
Very 0 (0%) 0 (0%)
most reported type of sound in both groups. To our knowledge,
dissatisfied this is the first study to describe the type of noise generation
based on implant design. In each group, the source of the noise
*Values are given as counts and percentages. felt or heard by patients was identified equally often as the
patella and the joint. This finding was in contrast to the results
of a previous study, which reported that the patella and joint
reportedly higher than that observed in other TKA implants6. were the most frequent locations of noise generation for
To date, we are not aware of any reports of noise generation posterior-stabilized TKA21.
with ultracongruent implants6. The patient perception of noise It was important to determine whether noise generation
generation is subjective, so it may be affected by the baseline actually affected clinical outcomes and patient discomfort, as
demographics of the patient. In the present study, 1 surgeon that could have affected patient satisfaction and the preference
randomly employed 2 TKA prosthesis designs, which were of implant design. Although the perception of noise generation
marketed by 1 company, on both knees of the same patient, and was significantly different between the 2 groups, there was no
therefore, the differences between operator techniques, patient difference in the level of patient discomfort caused by noise
baseline demographics, and differences among implant designs generation. The differences in noise generation between

TABLE V Preoperative and Postoperative FJS*

Preoperative 2 Years Postoperatively

Posterior-Stabilized Ultracongruent P Posterior-Stabilized Ultracongruent P
(N = 50) (N = 50) Value (N = 50) (N = 50) Value

Final FJS 30.3 ± 19.9 28.6 ± 19.1 0.666 77.2 ± 13.4 76.0 ± 14.4 0.674
1. In bed at night 1.1 ± 1.1 1.2 ± 1.0 0.700 0.1 ± 0.3 0.1 ± 0.3 1.000
2. When sitting on a chair for more than 1.9 ± 1.3 1.8 ± 1.3 0.875 0.2 ± 0.4 0.2 ± 0.5 1.000
1 hour
3. When walking for more than 15 2.8 ± 1.4 2.9 ± 1.4 0.828 1.4 ± 0.8 1.4 ± 0.9 0.820
minutes
4. When taking a bath/shower 2.6 ± 1.2 2.7 ± 1.2 0.564 0.3 ± 0.5 0.4 ± 0.6 0.710
5. When traveling in a car 2.5 ± 1.2 2.5 ± 1.2 0.933 0.4 ± 0.5 0.5 ± 0.7 0.337
6. When climbing stairs 3.4 ± 0.7 3.4 ± 0.8 0.897 1.8 ± 0.9 1.8 ± 0.9 0.824
7. When walking on uneven ground 3.2 ± 1.1 3.1 ± 1.1 0.717 1.0 ± 0.9 1.1 ± 0.9 0.823
8. When standing up from a low-sitting 3.2 ± 1.0 3.2 ± 1.1 1.000 1.5 ± 0.9 1.5 ± 1.0 1.000
position
9. When standing for long periods of time 2.9 ± 1.1 2.9 ± 1.0 0.775 0.8 ± 0.7 0.9 ± 0.9 0.604
10. When doing housework or gardening 3.1 ± 1.0 3.2 ± 1.0 0.767 0.8 ± 0.7 1.0 ± 0.8 0.336
11. When taking a walk or hiking 3.4 ± 1.0 3.4 ± 0.9 1.000 1.4 ± 0.8 1.6 ± 0.9 0.308
12. When doing a favorite sport 3.9 ± 0.7 3.9 ± 0.7 0.889 1.2 ± 0.8 1.3 ± 0.9 0.309

*Values are given as the mean and standard deviation. Raw FJS scores range from 12 to 60, with a higher raw score indicating a worse outcome,
whereas the final FJS score is expressed as a number between 0 and 100, with 0 being the worst and 100 the best. Patients were asked to rate
their awareness of the joint in each situation.
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TABLE VI Anteroposterior Stability at 90° in Patients with Ultracongruent TKA*

AP Stability
Study Brand Model AP Stability (UC Group) (Comparison Group)
35
Bignozzi et al. (2014) Waldemar Link Gemini 13.2 mm (AS) 13.3 mm (PS)
36
Sur et al. (2015) Stryker Triathlon 9.8 mm (CS) 3.0 mm (PS)
37
Appy Fedida et al. (2015) Stryker Triathlon 8.2 mm (UC) 1.4 mm (PS)
Mathys balanSys 8.4 mm (more 1.4 mm (PS)
deeply concave UC)
7
Lützner et al. (2015) Aesculap Columbus 11.9 mm (UC) 12.2 mm (CR)
31
Lützner et al. (2017) Aesculap Columbus 11.7 mm (UC) 6.3 mm (PS)
28
Fritzsche et al. (2018) Aesculap Columbus 13.8 mm (UC) 6.0 mm (PS)
16
Jang et al. (2019) Biomet Vanguard 7.6 mm (AS) 2.2 mm (PS)
Present study Zimmer Persona 4.5 mm (UC) 1.8 mm (PS)

*AP = anteroposterior, UC = ultracongruent, AS = anterior-stabilized, PS = posterior-stabilized, CS = condylar-stabilized, and CR = cruciate-retaining.

posterior-stabilized and ultracongruent TKA in this study were
not associated with patient-reported outcome measures.
We found no significant difference in range of motion
between groups, whereas previous studies have presented
various results on this subject. Fritzsche et al.28 and Machhindra
et al.29 reported that range of motion following posterior-
stabilized TKA was superior to that following ultracongruent
TKA; however, other studies have suggested that there was no
difference in range of motion between the 2 implant types30,31. A
meta-analysis concluded that posterior-stabilized TKA was
superior in terms of range of motion compared with ultra-
congruent TKA8. However, in the present study, there was no
difference in range of motion between the 2 implants.
In this study, posterior-stabilized TKA had better anter-
oposterior stability than ultracongruent TKA, which was in line
with the results of most previous studies (Table VI).
This study had several limitations. First, most of the
patients in this study were female (95%). This imbalance might
be more difficult to control because of the greater prevalence,
incidence, and severity of osteoarthritis in women than in
men32, especially because of the substantial sex differences
among Koreans33. Second, the follow-up period of 2 years was
relatively short; therefore, future long-term studies are needed
to clarify the results. Third, only 1 stress test was conducted to
evaluate the results, and we analyzed only static stability. In the
future, it may be necessary to evaluate dynamic stability,
including conducting gait analysis34. Fourth, it was difficult to
determine the exact cause of noise generation and whether it
was implant-related or derived from soft tissue. The causes of
noise generation were very diverse and complex23. The activities
associated with noise and the type of noise-pattern change were
not investigated in this study. However, the percentage of
patients reporting noise higher than following ultracongruent
TKA, as in previous studies6,21,22, indicating that bearing sur-
faces might be the source of noise generation in most cases.
Fifth, it was difficult to secure a perfect lateral radiographic
view, but we screened the available radiographs to select those
that most accurately represented a lateral view. Sixth, the
measurement of rollback on the lateral view may have had
limitations with respect to accurately identifying the contact
point between the implant and polyethylene. However, 2
readers evaluated the radiographs, and the interobserver reli-
ability was within an acceptable range. Finally, the study sample
size and power calculation were determined according to the
use of FJS. In addition, no post-hoc analyses were conducted
for significance because FJS was judged to be the most suitable
measure for evaluating the joint perception in TKA, and the
sample size was obtained using FJS only.
In conclusion, there were no significant differences
in patient-reported outcome measures including the FJS
between the ultracongruent and posterior-stabilized TKA
groups at 2 years postoperatively, obvious differences in
noise generation, and more sagittal laxity with less roll-back
in the ultracongruent TKA group. The clinical relevance of
the present study is that ultracongruent TKA may be an
alternative to posterior-stabilized TKA with similar patient-
reported outcomes. n
Man Soo Kim, MD, PhD1
In Jun Koh, MD, PhD2
Chul Kyu Kim, MD1
Keun Young Choi, MD1
Jin Hwa Jeon, MD1
Yong In, MD, PhD1
1Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of
Medicine, The Catholic University of Korea, Seoul, Republic of Korea
2Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital,
College of Medicine, The Catholic University of Korea, Seoul,
Republic of Korea
Email address for Y. In: iy1000@catholic.ac.kr
 52
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 103-A N U M B E R 1 J A N UA RY 6, 2 021
d d
ORCID iD for M.S. Kim: 0000-0002-1374-9964
ORCID iD for I.J. Koh: 0000-0002-7941-1587
ORCID iD for C.K. Kim: 0000-0001-7220-6938
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