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Osteolysis Associated with a Cemented tModular Posterior-Cruciate-Substituting Total Knee Design

Five to Eight-Year Follow-up

Investigation performed at the Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, and the Iowa Methodist Medical Center, Des Moines, Iowa

Michael R. O'Rourke, MD
John J. Callaghan, MD
Richard C. Johnston, MD
Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242. E-mail address for J.J. Callaghan: john-callaghan{at}uiowa.edu

Devon D. Goetz, MD
Patrick M. Sullivan, MD
Des Moines Orthopaedic Surgeons, 6001 Westown Parkway, West Des Moines, IA 50266

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. One or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (DePuy, Zimmer). In addition, a commercial entity (DePuy, Zimmer) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

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Background: Most intermediate and long-term studies of cemented posterior-cruciate-substituting total knee prostheses were performed with nonmodular tibial components. The purpose of this study was to evaluate the intermediate-term results of posterior-cruciate-substituting total knee arthroplasties in which a cemented modular tibial component had been used, with a particular focus on evaluating the prevalence of radiographic osteolysis.

Methods: Between 1992 and 1995, 176 consecutive primary total knee arthroplasties with use of the Insall-Burstein II system were performed in 134 patients at our institution. A modular metal-backed tibial component was inserted in 145 knees, and an all-polyethylene tibial component of the same design was inserted in thirty-one. Standard-terminology questionnaires were completed or Knee Society and The Hospital for Special Surgery scores were determined preoperatively and at the time of final follow-up, at an average of 6.4 years (range, 5.0 to 7.9 years). Initial postoperative radiographs were compared with those made at the time of final follow-up to assess component position, wear, radiolucent lines, and osteolysis.

Results: Ninety-two patients (128 knees) treated with the modular tibial component were alive at the time of final follow-up. No patient was lost to follow-up. Radiographs were available for 105 knees (82%). Three knees had been revised because of instability or infection; none had been revised because of loosening or osteolysis. The mean Knee Society clinical and functional scores were 85 points (range, 41 to 100 points) and 79 points (range, 30 to 100 points), respectively, at the time of final follow-up. According to The Hospital for Special Surgery score, 94% of the knees had a good or excellent result. Knee flexion averaged 113° (range, 90° to 130°) at the time of final follow-up. Osteolysis was present in seventeen (16%) of the knees with radiographic follow-up. Osteolysis did not develop in any knee in which an all-polyethylene tibial component had been used. Two knees (in one patient) were revised because of osteolytic lesions found at the time of follow-up for the study. Both of these knees had anterior wear of the tibial post due to impingement and backside tibial polyethylene wear.

Conclusions: Modular Insall-Burstein II total knee prostheses were found to function well after five to eight years of follow-up. However, the high prevalence of osteolysis in patients who had good or excellent clinical scores is worrisome. Particular attention should be paid to preventing flexion of the femoral component, posterior slope of the tibial component, or hyperextension of the knee when posterior-cruciate-substituting total knee arthroplasty is performed. We also recommend routine follow-up radiographs after all total joint arthroplasties to detect asymptomatic osteolytic changes.

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