The Journal of Arthroplasty Vol. 25 No.

4 2010

Case Report

Detection of Locking Bolt Loosening in the

Stem-Condyle Junction of a Modular Femoral
Stem in Revision Total Knee Arthroplasty
Jae-Min Ahn, MD, and Jeung-Tak Suh, MD

Abstract: We report one case of loosening of the locking bolt in the stem-condyle junction of a
constrained modular femoral component in revision total knee arthroplasty. Early detection of
loosening of the locking bolt was possible using reconstructed view of computerized tomography
scans before complete disengagement and radiographic loosening of the stemmed femoral
component. When using the Total Condyle III femoral component with a stem extension, surgeons
should keep in mind that stress concentration at the stem-condyle junction can result in failure of
the locking bolt although it is rare and that loosening or disengagement of the locking bolt may be a
sign of a loose stemmed femoral component. Keywords: revision knee arthroplasty, loosening,
locking bolt, stem-condyle junction, computerized tomography.
© 2010 Elsevier Inc. All rights reserved.

Revision total knee arthroplasty (TKA) in the presence of Case Report

poor bone stock often precludes the use of standard
implants. Implant fixation can be enhanced by the use of
intramedullary stems. With a failed TKA, increased
component constraint may be required to compensate
for ligamentous deficiencies. The modular femoral
components can be assembled with stems through a
taper junction, a locking bolt, or both. Modular designs
have become popular because they allow the surgeon to
achieve intraoperative customization and improved fixa-
tion [1]. Despite of these advantages of modularity, the
prosthetic stem-condyle junction becomes a potential
area for fatigue failure [2]. We report one case of
loosening of the locking bolt in the stem-condyle junction
of a constrained modular femoral component in revision
TKA. Early detection of loosening of the locking bolt was
possible using reconstructed view of computed tomogra-
phy (CT) scans before complete disengagement of the
locking bolt and definitive radiographic loosening of the
stemmed femoral component.
From the Department of Orthopedic Surgery, Pusan National University
School of Medicine, Busan, Korea.
Submitted December 17, 2008; accepted June 10, 2009.
No benefits or funds were received in support of the study.
Reprint requests: Jeung-Tak Suh, MD, Department of Orthopaedic
Surgery, Pusan National University Hospital, 1-10 Ami-dong, Seo-gu,
Busan 602-739, Korea.
© 2010 Elsevier Inc. All rights reserved.
0883-5403/2504-0038$36.00/0
doi:10.1016/j.arth.2009.06.014
A 67-year-old woman presented to our clinic with an
infected TKA. She underwent 2-stage reimplantation for
the infected TKA with antibiotic-loaded bone cement
spacers. After the infection was eradicated, Total Con-
dylar III component (DePuy Johnson and Johnson,
Warsaw, Ind) with modular stemmed femoral and tibial
components secondary to ligamentous laxity was used.
Two years after 2-stage revision surgery, the patient
complained of pain, recurrent swelling, and inability to
walk more than one block with the aid of a cane. Physical
examination revealed a range of motion of 0° to 60° and
joint effusion. Plain radiographs showed mild varus
collapse but no definitive sign of loosening around the
femoral component compared with postoperative radio-
graphs of initial revision surgery (Fig. 1A). The C-reactive
protein level, erythrocyte sedimentation rate, and white
blood cell count were all within normal limits. Aspiration
of fluid from the knee joint revealed clear fluid, and a
culture of aspirated fluid demonstrated no bacterial
growth. Therefore, we made a diagnosis of aseptic
loosening of femoral component, without a recurrence
of infection. A CT of the knee was performed, which
revealed loosening of the locking bolt in the stem-condyle
junction of the femoral component on the sagittal
reconstructed view (Fig. 1B). To reduce the metal-related
artifact on CT image, real-time adjustment of window
width and level was optimized on the picture archiving
and communication system (PACS) (Fig. 1C). Varus and
valgus stress radiographs, and full extension and flexion

660.e11
660.e12 The Journal of Arthroplasty Vol. 25 No. 4 June 2010

Fig. 1. (A) Anteroposterior and lateral radiographs, made 2 years after revision surgery, showed mild varus collapse of the femoral
component without definitive radiographic loosening. (B) Routine sagittal reconstructed image of computerized tomography scans
(window width 400 HU). (C) Adjusted same image on the PACS (window width 5000 HU) showed loosening of the locking bolt in
the stem-condyle junction more clearly. It was useful for accurate diagnosis and early detection of loosening of the locking bolt. (D)
Flexion-extension lateral radiographs showed loosening of locking bolt in the stem-condyle junction and loosening of the femoral
component with well-fixed stem.

lateral radiographs revealed loosening of the locking bolt,
varus collapse with bone loss in the medial femoral
condyle, and definitive loosening of femoral component
(Fig. 1D). At re-revision surgery, there was metallosis and
synovitis. The femoral component was loose distally with
extensive segmental and cavitary bone loss medially and
the femoral stem locking bolt was loose in the stem-
condyle junction. A femoral head allograft was used to
reconstruct the segmental and cavitary defect in the
medial femoral condyle. Three months after the surgery,
the patient had range of motion 0° to 100° with no pain
and could walk without any support.
Discussion
Many TKA revisions may involve severe bone loss and
ligamentous insufficiency. A stemmed component often
is required to share articular loads, to augment sub-
optimal distal condyle fixation, and to protect distal bone
grafts or ligamentous deficiencies [3]. Early femoral
component designs used nonmodular components. Mod-
ular designs have become popular. Concerns with respect
to modularity in TKA have arisen because of the many
junctions of modular components. Issues relating to
metallic wear, fretting, and corrosion between the body
of the prosthesis and the various modular components
require the surgeon to understand the potential long-
term problem and to proceed with caution [4]. With the
development of modular stems, the prosthetic stem-
condyle junction becomes a potential area for fatigue
failure [2]. The most highly constrained tibial insert
amplifies the stresses at the stem-condyle junction.
Loosening of the locking bolt at the modular junction
suggests fatigue failure associated with suboptimal bony
support due to loosening. Total knee arthroplasty designs
with increased constraint can serve as an adjunct in
stabilizing the joint [5-7], but the centralized tibial post
and femoral box constraint mechanism is at a mechanical
disadvantage to resisting the bending and torsion loads
applied across the joint [6]. Stem extensions can aid in
resisting the applied loads and can protect the cancellous
bone [8], but they are unable to resist the entire load
should no osseous support exist [5,7].
There are several articles regarding failure or fracture at
the modular junction of stemmed femoral components.
Westrich et al [1] reported 3 cases of disengagement of a
locking screw from the Insall-Burstein II Constrained
Condylar Knee (Zimmer, Warsaw, Ind) with press-fit
femoral stems. Stem-condyle junction has a Morse taper
junction with additional screw reinforcement. In 2 cases,
this disengagement was not associated with loosening of
the femoral component. In 1 case, after removal of the
screw, the patient developed loosening of the femoral
component and went on to revision. They concluded that
this mechanism of failure may be due to failure of proper
assembly of the modular components by the operative
team. Lim et al [2] reported 5 cases of failure at the stem-
condyle junction. All were associated with complete
disengagement of the locking bolt with dissociation of the
stem from the condyle portion from the Total Condylar III
femoral component (DePuy Johnson and Johnson). All
had well-fixed cemented femoral stems and distal
loosening of the femoral component. They recommended
using a nonmodular component or a component with a
Morse taper junction site.
The forces acting at the tibial component primarily are
axial compression. The femoral component undergoes not
 Locking Bolt Loosening in the Stem-Condyle Junction  Ahn and Suh
only axial compression but also significant flexion-exten-
sion and valgus-varus stress. Conceptually, forces trans-
ferred across the knee joint into the femoral condyles of the
component are transmitted proximally through the distal
host-femur and the stem [2]. In case of a modular stem, the
area of maximal stress concentration is at the stem-
component junction and at the proximal tip of the stem.
Lim et al [2] recommended that using a substantial Morse
taper junction site may help avoid the failures. However,
many articles contain examples of dissociation of modular
taper junctions in shoulder, knee, and hip implants
secondary to fluid contamination, galvanic corrosion,
fretting, or trauma [9]. Isaack et al [9] reported 2 cases of
fracture in the male portion of the taper junction of the
femoral component and stem extension.
Westrich et al [1] reported that among 3 cases of locking
screw disengagement, 2 cases had no occurrence of
loosening as there was no taper junction failure. However,
Lim et al [2] reported that all 5 cases with complete
disengagement of the locking bolt had femoral component
loosening and performed re-revision surgery. In our case,
it was not complete disengagement that occurred but
loosening of the locking bolt; re-revision surgery was
needed. Aseptic loosening of the stemmed femoral
components would likely increase stresses throughout
the stem and the condyle junction connection. The stem-
condyle junction may therefore be a weak area in the
implant and may be unable to withstand the concentrated
stresses that occur with loosening of the femoral compo-
nent. Unlike a taper type junction, the stem-condyle
junction of Total Condylar III component is assembled
with a locking bolt only; thus, failure of the locking bolt
can mean loosening of total femoral component.
Unlike the cases of Lim et al, it was possible to detect
loosening of the locking bolt in the early stage before
complete disengagement and definitive sign of radio-
graphic loosening of the stemmed femoral component.
And then, radiographic loosening of the stemmed
femoral component was confirmed by stress radiography.
To reduce the metal-related artifact on CT image, real-
time adjustment of window width and level was
optimized on the PACS. Yeom et al [10] reported that
examination of the Hounsfield number distribution on CT
scans reveals that for normal tissues the range is from
approximately −500 to +1400; that for metal artifact is
approximately +1300 to +3000; and that for the metal
itself is approximately +2300 to +3071. The Hounsfield
number indicates the gray level (intensity) of a CT scan
pixel. In our experience, adjustment of window level and
width on the PACS can help reduce metal-related
artifacts, particularly in a window width as large as
660.e13
4000 HU (Housfield unit). It was useful for early detection
of loosening of the locking bolt, although the metal
artifacts cannot be removed completely.
Although modularity offers the advantages of intrao-
perative versatility and improved fixation, there is the
potential for failure at the modular junction. When
using the Total Condylar III femoral component with a
stem extension, surgeons should keep in mind that
stress concentration at the stem-condyle junction can
result in failure of the locking bolt and that loosening
or disengagement of the locking bolt may be a sign of a
loose stemmed femoral component. Early detection of
loosening of locking bolt is important before the locking
bolt becomes completely disengaged and creates addi-
tional problems. Adjustment of window level and
width on the PACS can help reduce metal-related
artifacts. Adjusted CT image on the PACS was useful
for early detection of loosening of the locking bolt.
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