The impact of design changes intended to improve wear of knee replacements can be assessed from analysis of retrieved implants. We hypothesized changes in bearing surface conformity from the Insall-Burstein II knee to a successor, the Optetrak, intended to improve contact stresses would be apparent in wear patterns observed on retrieved tibial inserts. From 151 Insall-Burstein II and 54 Optetrak retrieved components, 35 pairs (Insall-Burstein II and Optetrak) were matched on length of implantation, body mass index, and age. Digital images of the bearing surfaces were used to identify and measure wear modes, which were then converted to a percentage of the total possible contact area. Burnishing was the most prevalent mode for both designs followed by scratching and then pitting. The percentage of involved area was greater for the Optetrak for 23 pairs. Interestingly, for the nine matched pairs with length of implantation longer than 2 years, six of the Insall-Burstein II inserts had considerably greater scratching and pitting and five exhibited abrasion and creep absent from Optetrak implants. Bearing surface design is a major factor that can affect kinematics and contact patterns. Our observations confirm the considerable impact of small changes in conformity and suggest models predicting contact stresses adequately reflect in vivo performance.