Wear and Osteolysis
Around Total Knee
Douglas D.R. Naudie, MD,
FRCSC
Deborah J. Ammeen, BSc
Gerard A. Engh, MD
Cecil H. Rorabeck, MD, FRCSC
Dr. Naudie is Assistant Professor,
Division of Orthopaedic Surgery,
University of Western Ontario, and
Director, Musculoskeletal Imaging Unit,
Robarts Research Institute, London,
ON, Canada. Ms. Ammeen is Project
Director, Clinical Knee Research,
Anderson Orthopaedic Research
Institute, Alexandria, VA. Dr. Engh is
Director, Knee Research, Anderson
Orthopaedic Research Institute. Dr.
Rorabeck is Professor, Division of
Orthopaedic Surgery, University of
Western Ontario.
Dr. Naudie or the department with which
he is affiliated has received research or
institutional support from DePuy and
Smith & Nephew. Ms. Ammeen has
received nothing of value from nor does
she own stock in a commercial company
or institution related directly or indirectly
to the subject of this article. Dr. Engh or
the department with which he is
affiliated has received royalties from
DePuy. Dr. Rorabeck or the department
with which he is affiliated has received
research or institutional support from
DePuy and Smith & Nephew.
Reprint requests: Dr. Naudie, Division of
Orthopaedic Surgery, University of
Western Ontario, London Health
Sciences Centre, Office B9-006,
University Campus, 339 Windermere
Road, London, ON, Canada N6A 5A5.
J Am Acad Orthop Surg 2007;15:
53-64
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.
Volume 15, Number 1, January 2007
Arthroplasty
Abstract
Osteolysis induced by wear debris of ultra-high-molecular-weight
polyethylene has emerged as a significant problem after total knee
arthroplasty. The generation of polyethylene wear and the
development of osteolysis around total knee arthroplasty are
caused by a combination of patient, implant, and surgical factors.
Activity level over time may be the most important patient factor
affecting the loads placed on a total knee replacement, but it is the
most difficult to manage. Multiple factors related to the
manufacturing of the polyethylene implant influence the extent of
wear, and surgeons should be cautious in considering enhanced
polyethylenes pending results of further investigations. The
optimal design of the articular bearing surface remains
controversial but needs to be considered with respect to the
stresses imparted on component-bone and modular tibial backside
interfaces. Surgical factors, including restoration of alignment and
ligament balance, are important for long-term durability of the
implant. Methods of measuring the wear of total knee implants are
still evolving. Thus, when confronted with a worn total knee
implant and developing osteolysis, the surgeon should consider
each of these factors in selecting the best management option to
eliminate the source of debris and minimize the potential for wear
and osteolysis following revision.
P olyethylene wear remains a ma-
jor limitation of the long-term
success of total knee arthroplasty
primarily as a result of microadhe-
sion and microabrasion.4 Polyethy-
lene wear also has been observed on
(TKA).1,2 Unlike the highly congruent the undersurface, or backside, of
ball-and-socket articulation in the modular tibial knee inserts.5-10
hip, the geometry and articulation of Osteolysis associated with poly-
the knee is complex. In TKA, poly- ethylene wear has been identified as
ethylene wear occurs from a combi- a significant problem with certain
nation of rolling, sliding, and rota- knee arthroplasty designs.11-15 The
tional motions through the bearing main causative factor leading to
surface, which may lead to delamina- periprosthetic osteolysis is small
tion, pitting, and fatigue failure of the particulate debris, which stimulates
polyethylene surface3 (Figure 1). a foreign-body cellular response re-
These wear mechanisms are different sulting in bone resorption.16,17 In try-
from those observed in total hip re- ing to resolve design issues and min-
placements, in which wear occurs imize wear with TKA, the amount
53
Wear and Osteolysis Around Total Knee Arthroplasty
Figure 1
Retrieved polyethylene insert of a failed
total knee arthroplasty, demonstrating
wear and delamination of the
polyethylene bearing surface.
(Reproduced from Naudie DDR,
Rorabeck CH: Sources of osteolysis
around total knee arthroplasty: Wear of
the bearing surface. Instr Course Lect
2004;53:251-259.)
of particulate debris, the composi-
tion of debris, and the location of de-
bris generation (articular or back-
side) all must be considered.
The Problem of
Osteolysis
The earliest reports of osteolysis
around total knee replacements de-
scribed bone resorption in associa-
tion with cementless implants.18-20
Holes in the tibial baseplate, tibial
fixation screws, and areas of un-
bonded or discontinuous porous
coating on the implant were impli-
cated as conduits for debris, ulti-
mately leading to osteolysis.21,22
Soon afterward, investigators recog-
nized that osteolysis also occurred
in association with total knee re-
placements in which components
were inserted with cement.12,23,24 In
these cases, debris particles were
thought to gain access to bone by
way of voids in the cement mantle.
The implant-bone interface was
therefore identified as an important
variable in the development of os-
teolysis because it provided me-
chanical stability to the prosthesis
and acted as a barrier to particulate
debris.
54
The type and composition of wear
debris particles have since been iden-
tified as other key factors in the gen-
eration of the osteolytic response.
Particles of polyethylene, polymeth-
ylmethacrylate, and metal have been
shown to be present in the debris of
failed TKAs and shown to elicit dis-
tinct inflammatory responses.17 In-
vestigators also have recognized that
debris from failed total knee prosthe-
ses consists of larger flake-shaped
particles compared to that from
failed total hip arthroplasties, and
the tissue response is characterized
by fewer macrophages.25 This sug-
gests that large polyethylene parti-
cles associated with delamination,
pitting, and fatigue wear do not elicit
the same cellular response as does
small-particle debris. Some studies
propose that osteolysis around mod-
ular TKA designs occurs as a result
of small-particle debris generated by
backside wear at the interface be-
tween the polyethylene insert and
the metal baseplate.5,9,10,26-29 There is,
however, no evidence to confirm
that small wear particles are pro-
duced only by backside wear or that
articular-side wear does not contrib-
ute to osteolysis.
Patient Factors
Many factors influence the amount
of wear and osteolysis that occurs
over time. Patient-related factors,
such as age, size, and activity level,
determine the amount and types
of load experienced by an im-
plant.9,30,31 Age alone is not indica-
tive of the usage of a total knee im-
plant, however, because younger
patients may have undergone knee
arthroplasty for inflammatory dis-
ease (eg, rheumatoid arthritis) that
itself limits activities. Similarly, a
patient’s body weight may have con-
tributed to the arthritis in the knee,
but it also may contribute to inactiv-
ity after TKA. Therefore, activity
level is likely the most important
patient factor affecting the loads
placed on a TKA over time. Howev-
Journal of the American Academy of Orthopaedic Surgeons
er, patient factors are the hardest to
manage. Active people generally se-
lect a knee replacement so that they
can remain active; these individuals
find it hard to give up or modify their
activities.
Implant Factors
Polyethylene Structure and
Thickness
Factors related to the material
properties of an implant also affect
its wear resistance and the genera-
tion of particulate debris.15 Polyeth-
ylene powder is generated by a
polymerization process whereby
ethylene monomers are linked to-
gether and transferred into a poly-
mer chain of carbon and hydrogen
groups. The physical properties and
molecular weight of polyethylene
are defined largely by the polymer-
ization process, which is affected by
conditions such as temperature and
pressure and by chemicals used as
catalysts in polymerization. Process-
ing flaws can result in subsurface
cracks, voids, or fusion defects that
can act as sites for delamination or
for further crack propagation when
these implants are loaded in vivo.
Authors of retrieval studies have
examined polyethylene bearings con-
taining processing defects and re-
ported higher rates of delamination
and total wear damage than in sim-
ilar bearings that are free of de-
fects.32,33 Studies also have shown
that polyethylene materials that are
free of defects demonstrate virtually
no delamination even after extended
duration in vivo.34 Over the years,
several attempts have been made to
enhance polyethylene, including by
heat pressing, carbon fiber reinforce-
ment, and alteration of its crystallin-
ity, but most of these changes re-
sulted in materials that were more
prone to fatigue modes of wear.35-37
Evidence also suggests that the
method of manufacturing polyethy-
lene may affect its clinical perfor-
mance and wear resistance. In gen-
eral, components are manufactured

Figure 2
Retrieved polyethylene insert that had
been sterilized by gamma radiation
in air, demonstrating regions of
oxidation and premature wear.
either by machining or by compres-
sion molding. Machined components
are made from either a polyethylene
sheet or bar stock; compression-
molded components are made by
molding the powder into the bearing-
surface geometry. Some investigators
have hypothesized that machining
components from extruded stock cre-
ates subsurface material cracking,
which results in delamination fail-
ure. Compression-molded tibial com-
ponents have exhibited less wear
than components machined from ex-
truded stock and may therefore be
preferable for clinical use.33,38-41
The method of sterilizing poly-
ethylene also has been shown to af-
fect its mechanical properties and
subsequent performance as a bearing
surface. Historically, most polyeth-
ylene used in knee arthroplasty was
sterilized by gamma radiation in air.
However, this method of steriliza-
tion created free radicals that per-
mitted oxidation to occur when the
sterilized product was stored for ex-
tended periods of time in an oxygen-
rich environment. Tibial compo-
nents sterilized and stored by this
method were found to exhibit a sub-
surface band of highly oxidized poly-
ethylene that contributed to a de-
crease in mechanical strength and a
propensity to premature wear based
on the time of insertion42,43 (Fig-
ure 2). The first clinical study to
Volume 15, Number 1, January 2007
Douglas D.R. Naudie, MD, FRCSC, et al
Figure 3
Volumetric wear rates of conventional polyethylene (CPE) and cross-linked
polyethylene (XPE) in clean and abrasive conditions for the hip and knee. Using hip
and knee simulators, XPE demonstrated dramatic reduction in volumetric wear
over CPE under clean (ie, nonabrasive) conditions. (Reproduced with permission
from Good V, Widding K, Scott M, Jani S: The sensitivity of crosslinked UHMPE to
abrasive wear: Hips vs. knees, in ASTM STP. West Conshohocken, PA: American
Society for Testing and Materials, 2002.)
demonstrate the deleterious effects wear resistance to the same degree
of oxidation was that of Bohl et al,44 as in total hip arthroplasty. For ex-
who reported a 21% failure rate from ample, under simulated abrasive
accelerated wear in implants with a conditions, cross-linked polyethy-
shelf age of 8 to 11 years. Fehring et lene is dramatically more sensitive
al14 recently correlated polyethylene to wear in the knee than in the hip15
shelf age with the development of (Figure 3). Under the simulated abra-
osteolysis around modular total sive conditions (which more closely
knee replacements. Implant manu- mimic the in vivo scenario) in the
facturers have since recognized hip, cross-linked polyethylene wear
these problems and changed their rates increased by at least 15-fold
methods of sterilization to ethylene from clean (ie, nonabrasive) to abra-
oxide gas or gamma radiation in an sive conditions, while the cross-
environment free of oxygen. linked polyethylene wear rate in the
Implant manufacturers also have abrasive conditions continued to be
begun to use high-dose electron- less than that of conventional poly-
beam or variable gamma radiation to ethylene wear rates. Conversely, in
create a stronger three-dimensional the knee, cross-linked polyethylene
structure of polyethylene. This pro- was more sensitive to abrasion than
cess, known as cross-linking, has in the hip, showing a 70-fold in-
been shown to offer improved resis- crease in wear in comparison to
tance to wear in total hip arthroplas- clean conditions; also, cross-linked
ty.45 However, controversy exists as polyethylene wear rates were higher
to whether cross-linked polyethy- than those of conventional polyeth-
lene bearing surfaces in TKA dem- ylene in the abrasive conditions.
onstrate the benefit of improved Other knee simulator studies, how-
55
Wear and Osteolysis Around Total Knee Arthroplasty

Figure 4 ever, have shown that highly cross-

linked polyethylenes reduce wear
and eliminate delamination.46,47 Be-
cause highly cross-linked polyethy-
lene tibial inserts have been in clin-
ical use only for a short time, their
application in TKA has not yet been
fully investigated.
Finally, the thickness of polyeth-
ylene should be considered when
evaluating wear resistance in TKA.
Bartel et al48 demonstrated that the
contact stresses in polyethylene in-
serts <6 mm thick increase exponen-
tially as the thickness of the implant
decreases (Figure 4). For example, in
very thin components, a small re-
duction in thickness generates a
large increase in contact stress and
less favorable wear characteristics.
Clinical reports of retrieved im-
plants have confirmed that thinner
Variation of the maximum (compressive) contact stress on the surface of the tibial
polyethylene components exhibit
component with varying thicknesses of the polyethylene layer. UHMWPE =
greater wear than do thicker compo-
ultra-high-molecular-weight polyethylene, C-UHMWPE = carbon-reinforced ultra-
high-molecular-weight polyethylene. (Adapted with permission from Bartel DL, nents of the same knee design3,49
Bicknell VL, Wright TM: The effect of conformity, thickness, and material on stresses (Figure 5). Authors of some series,
in ultra-high molecular weight components for total joint replacement. J Bone Joint however, have reported excellent re-
Surg Am 1986;68:1046.) sults despite very thin polyethylene
surfaces.50,51 Currently, a minimum
of 6 mm of polyethylene is required
Figure 5 by the FDA for new knee-implant
designs. For polyethylene inserts
>8 mm thick, the contact stresses
change minimally; accordingly, a
minimum polyethylene liner thick-
ness of 8 mm is generally recom-
mended. Surgeons should under-
stand, however, that the liner
thickness might be thinner for mod-
ular implants; that is, a 10-mm in-
sert is actually thinner (by the thick-
ness of the tibial tray) when using a
modular implant. For example, a 10-
mm modular insert, because it al-
lows for about 2 mm of thickness of
the tibial tray, may actually have
<8 mm of polyethylene liner thick-
ness.

Component Design: The

Articular Surface
Retrieved total knee replacement component demonstrating asymmetric
The greatest amount of polyeth-
(posteromedial) wear of the polyethylene bearing surface. (Adapted from Naudie
DDR, Rorabeck CH: Sources of osteolysis around total knee arthroplasty: Wear of ylene debris has long been thought
the bearing surface. Instr Course Lect 2004;53:251-259.) to come from wear of the articular
bearing surface.15,26 Appropriate

56 Journal of the American Academy of Orthopaedic Surgeons


bearing-surface designs aim to min-
imize contact loads and contact
stresses in order to maximize wear
resistance. Bartel et al48 showed that
the effect of contact load and stress
distribution at the bearing surface
depends on the contact area over
which weight-bearing stresses are
transferred. Bearing-surface designs
with small areas of contact between
the femoral and tibial components
distribute weight-bearing forces over
a smaller area, which in turn in-
creases the total amount of stress per
unit area that is transmitted to the
tibial polyethylene component.
Thus, bearing-surface designs with
small areas of contact may have less
favorable wear characteristics. Con-
versely, designs with the largest area
of contact allow weight bearing to be
distributed over a larger area, which
decreases the contact stresses and
maximizes wear resistance.
The area of contact between the
femoral and tibial components is de-
termined by the articular geometry
of the femoral component and the
polyethylene bearing surface. Poorly
conforming articulations have small
contact areas, increased contact
stresses, and theoretically less favor-
able wear characteristics. However,
poorly conforming articulations are
thought to reproduce more nearly
normally the physiologic move-
ments in the knee by allowing
motion to be dictated by the soft
tissues.52 Highly conforming, or
relatively congruent, articulations
maximize contact areas and wear re-
sistance, but they may decrease the
load carried by the surrounding soft
tissues and, subsequently, increase
stresses at the component-bone in-
terface.53
Cruciate-retaining implants were
designed with the idea of reproduc-
ing physiologic movements in the
knee by allowing motion to be dic-
tated by the soft tissues and liga-
mentous structures, particularly the
posterior cruciate ligament.51 How-
ever, several retrieval studies of rel-
atively flat cruciate-retaining tibial
Volume 15, Number 1, January 2007
inserts revealed high failure rates
from polyethylene wear.3,49,52-54 The
accelerated wear rates observed in
these studies were thought to result
from the higher contact stresses
placed through small contact areas
on the flat articular surface. A high-
er incidence of eccentric and asym-
metric wear patterns also was noted,
thought to result from soft-tissue
imbalances (Figure 5). The most
common wear patterns were typical-
ly located anteromedially and an-
terolaterally, likely the result of pro-
gressive subluxation of the femur
from posterior cruciate ligament
insufficiency.52-54 However, other re-
ports documented posterior wear
patterns of the tibial insert caused by
a tight posterior cruciate ligament
and/or external rotation of the tibial
tray.54,55 The fact that flat articulat-
ing geometries have not performed
inferiorly in clinical use suggests
that other variables may be more
important in the survival of these
bearing-surface designs.50,51,55
The concept that cruciate-
retaining implants provide more nor-
mal knee kinematics also has been
challenged recently by in vivo fluo-
roscopic measurements that have
demonstrated more erratic kine-
matic patterns for cruciate-retaining
implants.56,57 Dennis et al56 and Ko-
mistek et al57 have shown, for exam-
ple, that some cruciate-retaining
knees demonstrate paradoxical ante-
rior femoral translation with flexion
and therefore do not duplicate nor-
mal femoral rollback. These au-
thors56,57 have shown not only that
posterior stabilized designs demon-
strate more reproducible in vivo ki-
nematics but also that these designs
are unable to duplicate normal fem-
oral rollback. In addition, posterior
stabilized designs demonstrate
greater condylar lift-off during deep
knee flexion.57
Bearing surfaces with more con-
forming polyethylene inserts were
developed to prevent asymmetric
wear patterns and reduce wear rates.
Partially conforming implants, using
Douglas D.R. Naudie, MD, FRCSC, et al
a dished polyethylene insert and a
raised anterior lip, were developed to
improve anteroposterior stability
and thus prevent uncontrolled slid-
ing of the femoral component. In
some studies, these implants dem-
onstrated good clinical success and
a low incidence of polyethylene
wear.58 Retrieval studies also con-
firmed that these more conforming
designs exhibited lower wear rates
and fewer eccentric wear patterns
than did less conforming de-
signs.3,49,53
Posterior-stabilized designs were
developed because of the technical
difficulties encountered in trying to
correct significant clinical deformity
with partially conforming designs.
They employ a highly conforming or
relatively congruent articulation.
Posterior-stabilized designs use a tib-
ial polyethylene post in the middle
of the knee and a cam between the
femoral condyles to prevent poste-
rior subluxation of the tibia. These
designs decrease load carried by the
surrounding soft tissues and likely
provide a more predictable kine-
matic path of the knee; however, the
trade-off is increased stresses at dif-
ferent knee interfaces, including
component-bone and modular tibial
interfaces.56,57
Although these designs may in-
crease the likelihood of motion and
wear at the modular backside inter-
face, many of them have demon-
strated excellent long-term clinical
success.12,13 However, the polyethyl-
ene tibial post has recently been
identified as an additional source of
polyethylene debris, and several
studies have reported that wear of
the polyethylene post has resulted in
fracture of the post or clinical
instability58-62 (Figure 6). What re-
mains unclear, however, is whether
damage to the tibial polyethylene
post occurs as a result of normal
function from wear on the posterior
surface of the post or as a result of
pathologic motion (relative hyperex-
tension of the components) leading
to anterior cam-post impingement.
57
Wear and Osteolysis Around Total Knee Arthroplasty
Figure 6
Retrieved polyethylene insert from a
posterior-stabilized total knee
arthroplasty component demonstrating
fracture of the tibial polyethylene post.
(Adapted from Puloski SK, McCalden
RW, MacDonald SJ, Rorabeck CH,
Bourne RB: Tibial post wear in
posterior stabilized total knee
arthroplasty: An unrecognized source
of polyethylene debris. J Bone Joint
Surg Am 2001;83:390-397.)
Mobile-bearing implants were de-
signed to allow very high conformi-
ty between articulating surfaces and
to provide more nearly normally the
physiologic knee kinematics. These
designs have a high degree of confor-
mity and, therefore, a large surface-
contact area, which, as noted, is fa-
vorable in terms of maximizing wear
resistance.63 These designs also have
a mobile tibial polyethylene bearing,
which permits rotation and/or trans-
lation during weight bearing. The
theoretic advantage offered by
mobile-bearing implants over fixed-
bearing surfaces is that of self-
correcting, internally or externally
rotated tibial components. These de-
signs avoid the effect of posterome-
dial or posterolateral tibial polyeth-
ylene wear. Although these implants
were designed for motion to occur
between the polished metal and
plastic surfaces, these surfaces are
not impervious to the effects of wear
debris. Any debris that does get
trapped between these two relative-
ly large surfaces can create addition-
58
Figure 7
A, Retrieved polyethylene insert demonstrating evidence of wear on the
undersurface of the insert. B, Retrieved tibial baseplate demonstrating stippling on
the top of the corresponding metal tibial tray.
al debris and thus damage the mod-
ular interface. Very good mid- and
long-term clinical results have been
reported with several mobile-bearing
designs, but osteolysis still has been
shown to develop in some of these
implant designs.11,64,65
Component Design: The
Backside
Metal backing and modularity of
the tibial component were intro-
duced in TKA to improve fixation
and address aseptic loosening.9 Metal
backing was added primarily to
lessen stresses on cement and bone
in an attempt to reduce tibial compo-
nent loosening. Modularity provided
a means of augmenting cementless
tibial component fixation; it also cre-
ated an opportunity to use polyeth-
ylene inserts of different thicknesses
with varying degrees of constraint.
Although metal backing and modu-
larity provided improved tibial com-
ponent fixation, they limited the
polyethylene thickness that could be
used without making additional bone
resections. In addition, this compo-
nent design change created a new in-
terface for wear between the polyeth-
ylene insert and the metal tibial
baseplate.5-10,27,28
In 1992, Peters et al18 published
the first case report series of osteol-
Journal of the American Academy of Orthopaedic Surgeons
ysis following TKA; they noted a
16% incidence of osteolysis with one
of the first modular metal-backed
implants approved for general use.
After examining the retrieved tibial
components, the authors reported
fatigue-type wear modes, such as pit-
ting and delamination, on the artic-
ular surface of the polyethylene com-
ponents but not on the underside.
On the undersurface of most of the
polyethylene inserts, screw-hole im-
pressions were often observed, and,
in retrieved implants in which the
modular insert was larger than the
metal tray, a lip of polyethylene was
identified on the overhanging edge
and in the recess of the metal tray for
the posterior cruciate ligament. The
authors reasoned that these screw-
hole impressions and nonloaded ar-
eas could be accounted for only by
loss of material in adjacent areas on
the underside of the polyethylene in-
sert (Figure 7, A).
The findings of the study from
Peters et al18 led to further investiga-
tions about the quality of the lock-
ing mechanisms between the tibial
tray and polyethylene insert for
modular knee arthroplasty designs.
Parks et al6 initiated a study to me-
chanically test the locking mecha-
nism used to connect the polyethy-
lene insert and the metal tibial tray

in nine types of commercially avail-
able total knee implants. The au-
thors reported appreciable motion
with both the snap-fit and the
tongue-in-groove locking mecha-
nisms. Engh et al7 subsequently con-
ducted a retrieval study to determine
whether locking mechanisms be-
came unstable over time with in
vivo stresses. The same testing pro-
tocol of Parks et al6 was repeated, us-
ing retrieved implants with the same
locking mechanisms. The authors
demonstrated motion indexes an or-
der of magnitude greater than those
of fresh, out-of-the-box implants.
These findings suggested that lock-
ing mechanisms lose stability under
repetitive loads in vivo. The magni-
tude of relative motion that occurs,
however, has since been shown to be
smaller under physiologic loads than
in the unloaded condition.8
In a final study of the same group
of retrieved modular tibial compo-
nents, Rao et al28 stereoscopically
examined wear of the tibial base-
plate. Baseplate wear grades corre-
lated with time in situ but demon-
strated an even stronger correlation
with an insert motion index. These
authors also identified an organized
pattern of discrete markings on the
tibial baseplate, referred to as stip-
pling (Figure 7, B). These marks were
organized in a fashion that strongly
indicated rotation of the insert on
the tibial baseplate. The existence of
a dominant pattern of marks for
each implant suggested that they
were directly related to the design of
the locking mechanism. The speci-
mens examined consisted of 10
baseplates made of titanium alloy
and 7 of cobalt-chromium alloy; the
authors identified no significant dif-
ference between the type of alloy
and insert motion index, backside
polyethylene wear score, or base-
plate wear score. Some investigators
have suggested that polished base-
plates of harder materials, such as
cobalt-chromium alloy, are more
scratch-resistant, which may reduce
wear on the undersurface of the
Volume 15, Number 1, January 2007
abutting polyethylene surface and,
therefore, are more desirable in clin-
ical use.60
These studies led several centers
to reconsider the use of an all-
polyethylene or nonmodular metal-
backed tibial knee design, with the
intent of minimizing backside wear
and interface motion. Two separate
centers performed matched-pair
analyses of all-polyethylene versus
metal-backed tibial components;
they found no statistically signifi-
cant differences in clinical perfor-
mance or functional and radiograph-
ic outcomes.66,67 Brassard et al68
performed a similar study compar-
ing monoblock and modular Insall-
Burstein posterior-stabilized im-
plants (Zimmer, Warsaw, IN); they
reported no statistical difference be-
tween the type of knee implant and
functional scores. They also report-
ed a lower incidence of radiolucent
lines in the monoblock design. A re-
port of a survivorship analysis of
more than 11,000 knees from the
Mayo Clinic database indicated a
significantly (P < 0.0001) higher 10-
year survival rate in knees that em-
ployed an all-polyethylene tibial
component.69 Most recently, Berend
et al55 reported that osteolysis has
not been a problem with the AGC
(Biomet, Warsaw, IN) nonmodular
metal-backed design.
Femoral Counter-Surface
Roughness
The surface characteristics of the
femoral component, or femoral
counter surface, also must be consid-
ered when evaluating wear in TKA.
Experimental studies in total hip re-
placement have demonstrated that
increased roughness of the femoral
head leads to accelerated polyethy-
lene wear.70 Hypothetically, similar-
ly high wear rates will be observed
from poorly polished femoral com-
ponents in TKA; to date, however,
no published studies are available to
support this hypothesis.
In a recent study, Puloski et al71
examined the surface characteristics
Douglas D.R. Naudie, MD, FRCSC, et al
of nine new femoral components
commonly used in TKA. The study
was conducted using stereomicros-
copy and light profilometry over
multiple surface points, including
the cam. The results showed that
the roughness parameters measured
from the condylar and trochlear sur-
faces were similar from one manu-
facturer to the other. However, the
authors found that, in six of the nine
components, the cam was uniform-
ly rougher than the condylar or
trochlear surfaces of the implant.
These findings raise the concern that
the cam-post articulation might con-
tribute to wear debris and thus
should be optimized during implant
manufacturing.
Surgical Factors
Good surgical technique is required
to minimize polyethylene wear and
subsequent osteolysis around total
knee implants.72 Poor alignment of
knee components may occur at the
time of surgery in the coronal, sagit-
tal, or rotational planes. Failure to
restore the mechanical axis of the
limb at the time of surgery may re-
sult in increased loading forces
across the bearing surface, leading to
early degradation of the polyethy-
lene. Minor deviations from a neu-
tral mechanical axis may contribute
to accelerated wear that is not evi-
dent until the implant has been
functioning for many years. In a re-
cent study that analyzed the influ-
ence of alignment on the wear of
retrieved tibial components, the
location of wear strongly correlated
with the location of the mechanical
axis.31
Imbalance in the sagittal plane
can result in a higher incidence of
eccentric and asymmetric wear
patterns with cruciate-retaining
designs.52-54 Imbalance in the sagittal
plane also can allow hyperextension
of the knee and lead to anterior cam-
post impingement with posterior-
stabilized designs.52-54,59-62 Internal or
external rotation of the femoral or
59
Wear and Osteolysis Around Total Knee Arthroplasty
Figure 8
Standing anteroposterior radiograph of a patient 10 years after right total knee
arthroplasty, demonstrating marked and asymmetric reduction in polyethylene joint
space.
tibial components in the rotational
plane, particularly in cruciate-
retaining designs, also may lead to
abnormal contact and accelerated or
asymmetric wear patterns.52-54 Ele-
vation of the joint line and failure to
restore normal patellofemoral track-
ing is also thought to result in signif-
icant, abnormal rotational wear pat-
terns. These studies emphasize the
importance of alignment and liga-
ment balance for durable arthroplas-
ty function.
Measuring Wear and
Osteolysis
Although several reliable methods
exist for measuring polyethylene
wear in total hip arthroplasty, meth-
ods for accurate radiographic mea-
surement of polyethylene wear after
TKA have only recently been
developed.26,73-75 Although methods
for measuring wear continue to be
improved and validated, the use of
plain radiographs, taken with the pa-
60
tient standing, to identify joint-space
narrowing remains the technique
most commonly used (Figure 8). If
the x-ray beam is parallel to the top
of the tibial tray and the femoral
component resides in the area of
minimal polyethylene thickness,
measuring the distance between the
femoral condyle and the tibial base-
plate on an anteroposterior radio-
graph has been shown to be accurate
to within 1 mm.73 Simple asymme-
try of the joint space on knee replace-
ment radiographs, however, does not
necessarily prove that polyethylene
wear is present because ligamentous
laxity on one side of the knee may
appear as joint-space narrowing in
the opposite compartment.
Osteolysis around a TKA can usu-
ally be visualized on plain radio-
graphs as a radiolucency with a scle-
rotic border (Figure 9). Determining
the extent of osteolysis on plain ra-
diographs can be difficult, however,
because this modality provides only
a two-dimensional projection of the
Journal of the American Academy of Orthopaedic Surgeons
Figure 9
Anteroposterior radiograph of a large
osteolytic lesion in the medial femoral
condyle, which appeared 5 years after
primary total knee arthroplasty.
complex three-dimensional geome-
tries of the femoral and tibial
components.76-79 Osteolysis of the
distal femur is often obscured by the
femoral component on an anteropos-
terior radiograph and usually can be
visualized best as a radiolucency
around the posterior condyles on the
lateral radiograph; an osteolytic le-
sion in one condyle, however, may
be masked by the presence of
healthy trabecular bone in the oppo-
site condyle. Osteolysis of the tibia
tends to occur along the periphery of
the tibial component and is usually
best seen on anteroposterior knee ra-
diographs along the medial and later-
al borders of the component and on
lateral radiographs along the antero-
posterior borders of the component.
Osteolysis of the patella typically
occurs around the margin of the im-
plant or along the implant-bone or
cement-bone interfaces and is best
seen on patellar skyline or lateral
knee radiographs. Although three-
dimensional imaging modalities,
such as computed tomography or
magnetic resonance imaging, have

not been used routinely to evaluate
osteolysis around knee implants,
they hold the promise of improving
accuracy in the future.
Management
The clinical significance of wear and
osteolysis around total knee im-
plants relates mainly to the extent of
the disease process. Usually, patients
early in the evolution of osteolysis
are asymptomatic, and the amount
of wear and bone resorption is limit-
ed. In such cases, osteolytic lesions
may be visible on radiographs but
are of little clinical significance to
the patient. In these patients, serial
radiographs are essential to evaluate
the progression of lesions. However,
the rate of progression of osteolytic
lesions varies. In some cases, lesions
have been followed for several years
with only minimal changes in the
radiographic appearance (Figure 10).
Because these lesions are often
asymptomatic and slowly progres-
sive, revision may not be necessary
when they are first identified. Most
cases of osteolysis, however, progress
with time.15 Loss of bone support
Figure 11
Posteroanterior (A) and lateral (B) radiographs of a patient with severe osteolysis around the tibial stem of his primary total knee
replacement, which resulted in fracture of the tibial baseplate of his implant. C, The removed tibial component. (Reproduced
from Naudie DDR, Rorabeck CH: Sources of osteolysis around total knee arthroplasty: Wear of the bearing surface. Instr
Course Lect 2004;53:251-259.)
Volume 15, Number 1, January 2007
Douglas D.R. Naudie, MD, FRCSC, et al
from osteolysis can lead not only to Figure 10
prosthetic loosening and clinical fail-
ure of the implant but also to weak-
ness in the periprosthetic osseous
support about the implant, resulting
in periprosthetic or component frac-
ture79,80 (Figure 11).
The timing of surgical interven-
tion for an osteolytic lesion is con-
troversial. The decision to operate
on a patient with osteolysis is based
on the presence of symptoms and
the likelihood that, if surgery is not
performed, a well-fixed implant may
become loose during the patient’s
lifetime. In general, we recommend
surgery in most symptomatic pa-
tients and in asymptomatic patients
when the osteolytic lesion is rapidly
increasing in size and seems to be
eroding the cortical support for the
implant. We would not routinely op-
erate on asymptomatic patients who
have osteolytic lesions that do not
disturb cortical bone support. In the
absence of instability, malalign- Anteroposterior radiograph of a large
ment, and significant backside wear osteolytic lesion in the lateral aspect of
in carefully selected patients, we the tibial plateau that appeared 9 years
after primary total knee arthroplasty.
would consider component reten-
tion, modular polyethylene ex-
61
Wear and Osteolysis Around Total Knee Arthroplasty
change, and morcellized bone graft-
ing of the osteolytic defect.
When revision surgery is indi-
cated, effort should be made to iden-
tify the underlying cause of the wear
and osteolysis. Malalignment and in-
stability usually are apparent on
physical examination and may be the
cause or the result of significant poly-
ethylene wear. Most commonly, ac-
celerated polyethylene wear occurs
as a result of loss of material, which
in turn reduces ligament support to
the knee and further aggravates both
malalignment and instability. This
combination frequently results in
debris-generated bone defects, which
may require the use of bulk allografts
and stemmed tibial components.81
With revision arthroplasty, every
effort should be made to restore
alignment and stability if the pro-
cess of wear and osteolysis are to be
avoided. When wear and osteolysis
occur in the absence of significant
malalignment or instability, an at-
tempt should be made to identify the
implant type. The surgeon may
choose to obtain the product identi-
fication numbers from the hospital
records. Although this is not practi-
cal for most surgeons, this informa-
tion can help determine whether
failure occurred in association with
polyethylene that was not manufac-
tured or sterilized according to the
most currently desirable methods.
Whenever a modular implant is
present, backside wear also should
be considered as a potential contrib-
utor to the osteolytic process. Recog-
nizing that backside wear may be a
contributing source of debris is the
first step in eliminating backside
wear during the revision surgery.
When backside wear is present on
the insert, modular insert exchange
may not be the best management op-
tion during revision surgery.82
Summary
The generation of polyethylene
wear and development of osteolysis
around TKA are caused by a combi-
62
nation of patient, implant, and sur-
gical factors. Osteolysis is most
commonly the result of the produc-
tion of biologically active polyethyl-
ene debris. Polyethylene debris par-
ticles may originate from both the
articular bearing surface and modu-
lar component backside surfaces.
Many factors related to the manu-
facturing and design of the articular
bearing surface influence the extent
of polyethylene wear generated over
time; surgeons should be cautious in
considering enhanced polyethyl-
enes until further investigations are
performed. Surgeons also should be
aware of backside wear and under-
stand the problems associated with
modular baseplates and their lock-
ing mechanisms for polyethylene
inserts. Alignment and stability in
the sagittal, coronal, and rotational
planes are important for durability
of the implant. Orthopaedic sur-
geons must understand the factors
that contribute to wear and osteoly-
sis to maximize the longevity of
TKA.
References
Evidence-based Medicine: Prospec-
tive randomized studies of level I/II
are limited (refs 56, 57 and 68) to
multicenter analysis and in vivo
analysis. The majority of references
are case-controlled or cohort studies
(level III/IV) and expert opinion (lev-
el V).
Citation numbers printed in bold
type indicate references published
within the past 5 years.
1. Lonner JH, Siliski JM, Scott RD: Pro-
dromes of failure in total knee arthro-
plasty. J Arthroplasty 1999;14:488-
492.
2. Sharkey PF, Hozack WJ, Rothman
RH, Shastri S, Jacoby SM: Insall
Award paper: Why are total knee ar-
throplasties failing today? Clin
Orthop Relat Res 2002;404:7-13.
3. Collier JP, Mayor MB, McNamara JL,
Surprenant VA, Jensen RE: Analysis of
the failure of 122 polyethylene inserts
from uncemented tibial knee compo-
nents. Clin Orthop Relat Res 1991;
Journal of the American Academy of Orthopaedic Surgeons
273:232-242.
4. McKellop HA, Campbell P, Park SH,
et al: The origin of submicron poly-
ethylene wear debris in total hip ar-
throplasty. Clin Orthop Relat Res
1995;311:3-20.
5. Wasielewski RC, Parks N, Williams I,
Surprenant H, Collier JP, Engh G: Tib-
ial insert undersurface as a contribut-
ing source of polyethylene wear de-
bris. Clin Orthop Relat Res 1997;
345:53-59.
6. Parks NL, Engh GA, Topoleski LD,
Emperado J: The Coventry Award:
Modular tibial insert micromotion. A
concern with contemporary knee im-
plants. Clin Orthop Relat Res 1998;
356:10-15.
7. Engh GA, Lounici S, Rao AR, Collier
MB: In vivo deterioration of tibial
baseplate locking mechanisms in
contemporary modular total knee
components. J Bone Joint Surg Am
2001;83:1660-1665.
8. Conditt MA, Ismaily SK, Alexander
JW, Noble PC: Backside wear of ultra-
high molecular weight polyethylene
tibial inserts. J Bone Joint Surg Am
2004;86:1031-1037.
9. Engh GA, Ammeen DJ: Epidemiology
of osteolysis: Backside implant wear.
Instr Course Lect 2004;53:243-249.
10. Conditt MA, Thompson MT, Usrey
MM, Ismaily SK, Noble PC: Backside
wear of polyethylene tibial inserts:
Mechanism and magnitude of materi-
al loss. J Bone Joint Surg Am 2005;87:
326-331.
11. Huang CH, Ma HM, Liau JJ, Ho FY,
Cheng CK: Osteolysis in failed total
knee arthroplasty: A comparison of
mobile-bearing and fixed-bearing
knees. J Bone Joint Surg Am 2002;84:
2224-2229.
12. O’Rourke MR, Callaghan JJ, Goetz DD,
Sullivan PM, Johnston RC: Osteolysis
associated with a cemented modular
posterior-cruciate-substituting total
knee design: Five to eight-year follow-
up. J Bone Joint Surg Am 2002;84:
1362-1371.
13. Lachiewicz PF, Soileau ES: The rates
of osteolysis and loosening associated
with a modular posterior stabilized
knee replacement: Results at five to
fourteen years. J Bone Joint Surg Am
2004;86:525-530.
14. Fehring TK, Murphy JA, Hayes TD,
Roberts DW, Pomeroy DL, Griffin
WL: Factors influencing wear and
osteolysis in press-fit condylar modu-
lar total knee replacements. Clin
Orthop Relat Res 2004;428:40-50.
15. Naudie DDR, Rorabeck CH: Sources
of osteolysis around total knee arthro-

plasty: Wear of the bearing surface.
Instr Course Lect 2004;53:251-259.
16. Howie DW, Vernon-Roberts B, Oake-
shott R, Manthey B: A rat model of re-
sorption of bone at the cement-bone
interface in the presence of polyethy-
lene wear particles. J Bone Joint Surg
Am 1988;70:257-263.
17. Jacobs JJ, Roebuck KA, Archibeck M,
Hallab NJ, Glant TT: Osteolysis: Ba-
sic science. Clin Orthop Relat Res
2001;393:71-77.
18. Peters PC Jr, Engh GA, Dwyer KA,
Vinh TN: Osteolysis after total knee
arthroplasty without cement. J Bone
Joint Surg Am 1992;74:864-876.
19. Berry DJ, Wold LE, Rand JA: Extensive
osteolysis around an aseptic, stable,
uncemented total knee replacement.
Clin Orthop Relat Res 1993;293:204-
207.
20. Engh GA, Parks NL, Ammeen DJ: Tib-
ial osteolysis in cementless total knee
arthroplasty: A review of 25 cases
treated with and without tibial com-
ponent revision. Clin Orthop Relat
Res 1994;309:33-43.
21. Lewis PL, Rorabeck CH, Bourne RB:
Screw osteolysis after cementless to-
tal knee replacement. Clin Orthop
Relat Res 1995;321:173-177.
22. Whiteside LA: Effect of porous-
coating configuration on tibial osteol-
ysis after total knee arthroplasty.
Clin Orthop Relat Res 1995;321:92-
97.
23. Ries MD, Guiney W Jr, Lynch F: Os-
teolysis associated with cemented to-
tal knee arthroplasty: A case report.
J Arthroplasty 1994;9:555-558.
24. Robinson EJ, Mulliken BD, Bourne
RB, Rorabeck CH, Alvarez C: Cata-
strophic osteolysis in total knee re-
placement: A report of 17 cases. Clin
Orthop Relat Res 1995;321:98-105.
25. Schmalzried TP, Jasty M, Rosenberg
A, Harris WH: Polyethylene wear de-
bris and tissue reactions in knee as
compared to hip replacement prosthe-
ses. J Appl Biomater 1994;5:185-190.
26. Schmalzried TP, Callaghan JJ: Wear in
total hip and knee replacements.
J Bone Joint Surg Am 1999;81:115-
136.
27. Engh GA, Ammeen DJ: Polyethylene
wear. Clin Orthop Relat Res 2002;
404:71-74.
28. Rao AR, Engh GA, Collier MB, Louni-
ci S: Tibial interface wear in retrieved
total knee components and correla-
tions with modular insert motion.
J Bone Joint Surg Am 2002;84:1849-
1855.
29. Huang CH, Ho FY, Ma HM, et al: Re-
lated particle size and morphology of
Volume 15, Number 1, January 2007
UHMWPE wear debris in failed total
knee arthroplasties: A comparison be-
tween mobile bearing and fixed bear-
ing knees. J Orthop Res 2002;20:
1038-1041.
30. Kuster MS, Stachowiak GW: Factors
affecting polyethylene wear in total
knee arthroplasty. Orthopedics 2002;
25(2 suppl):S235-S242.
31. Collier MB, Engh CA Jr, Engh G: The
correlation between limb alignment
and polyethylene wear in retrieved to-
tal knee arthroplasties. J Bone Joint
Surg Am, in press.
32. Wrona M, Mayor MB, Collier JP, Jen-
sen RE: The correlation between fu-
sion defects and damage in tibial poly-
ethylene bearings. Clin Orthop Relat
Res 1994;299:92-103.
33. Tanner MG, Whiteside LA, White SE:
Effect of polyethylene quality on wear
in total knee arthroplasty. Clin
Orthop Relat Res 1995;317:83-88.
34. Landy MM, Walker PS: Wear of ultra-
high-molecular-weight polyethylene
components of 90 retrieved knee pros-
theses. J Arthroplasty 1988;3 suppl:
S73-S85.
35. Li S, Burstein AH: Ultra-high molecu-
lar weight polyethylene: The material
and its use in total joint implants.
J Bone Joint Surg Am 1994;76:1080-
1090.
36. Ahn NU, Nallamshetty L, Ahn UM,
et al: Early failure associated with the
use of Hylamer-M spacers in three pri-
mary AMK total knee arthroplasties.
J Arthroplasty 2001;16:136-139.
37. Ries MD, Bellare A, Livingston BJ, Co-
hen RE, Spector M: Early delamina-
tion of a Hylamer-M tibial insert.
J Arthroplasty 1996;11:974-976.
38. Won CH, Rohatgi S, Kraay MJ, Gold-
berg VM, Rimnac CM: Effect of resin
type and manufacturing method on
wear of polyethylene tibial compo-
nents. Clin Orthop Relat Res 2000;
376:161-171.
39. Currier BH, Currier JH, Collier JP,
Mayor MB: Effect of fabrication meth-
od and resin type on performance of
tibial bearings. J Biomed Mater Res
2000;53:143-151.
40. Benson LC, DesJardins JD, LaBerge M:
Effects of in vitro wear of machined
and molded UHMWPE tibial inserts
on TKR kinematics. J Biomed Mater
Res 2001;58:496-504.
41. Berzins A, Jacobs JJ, Berger R, et al:
Surface damage in machined ram-
extruded and net-shape molded re-
trieved polyethylene tibial inserts of
total knee replacements. J Bone Joint
Surg Am 2002;84:1534-1540.
42. Collier JP, Sutula LC, Currier BH, et
Douglas D.R. Naudie, MD, FRCSC, et al
al: Overview of polyethylene as a
bearing material: Comparison of ster-
ilization methods. Clin Orthop Relat
Res 1996;333:76-86.
43. Collier JP, Sperling DK, Currier JH,
Sutula LC, Saum KA, Mayor MB: Im-
pact of gamma sterilization on clini-
cal performance of polyethylene in
the knee. J Arthroplasty 1996;11:
377-389.
44. Bohl JR, Bohl WR, Postak PD, Green-
wald AS: The Coventry Award: The
effects of shelf life on clinical out-
come for gamma sterilized polyethy-
lene tibial components. Clin Orthop
Relat Res 1999;367:28-38.
45. McKellop H, Shen FW, Lu B, Camp-
bell P, Salovey R: Development of an
extremely wear-resistant ultra high
molecular weight polyethylene for to-
tal hip replacements. J Orthop Res
1999;17:157-167.
46. Muratoglu OK, Mark A, Vittetoe DA,
Harris WH, Rubash HE: Polyethylene
damage in total knees and use of high-
ly crosslinked polyethylene. J Bone
Joint Surg Am 2003;85(suppl 1):S7-
S13.
47. Muratoglu OK, Bragdon CR, Jasty M,
O’Connor DO, Von Knoch RS, Harris
WH: Knee-simulator testing of con-
ventional and cross-linked polyethyl-
ene tibial inserts. J Arthroplasty
2004;19:887-897.
48. Bartel DL, Bicknell VL, Wright TM:
The effect of conformity, thickness,
and material on stresses in ultra-high
molecular weight components for to-
tal joint replacement. J Bone Joint
Surg Am 1986;68:1041-1051.
49. Hirakawa K, Bauer TW, Stulberg BN,
Wilde AH, Borden LS: Characteriza-
tion of debris adjacent to failed knee
implants of 3 different designs. Clin
Orthop Relat Res 1996;331:151-158.
50. Meding JB, Ritter MA, Faris PM: Total
knee arthroplasty with 4.4 mm of tib-
ial polyethylene: 10-year followup.
Clin Orthop Relat Res 2001;388:112-
117.
51. Ritter MA, Worland R, Saliski J, et al:
Flat-on-flat, nonconstrained, com-
pression molded polyethylene total
knee replacement. Clin Orthop
Relat Res 1995;321:79-85.
52. Feng EL, Stulberg SD, Wixson RL: Pro-
gressive subluxation and polyethy-
lene wear in total knee replacements
with flat articular surfaces. Clin
Orthop Relat Res 1994;299:60-71.
53. Benjamin J, Szivek J, Dersam G, Pers-
selin S, Johnson R: Linear and volumet-
ric wear of tibial inserts in posterior
cruciate-retaining knee arthroplasties.
63
Wear and Osteolysis Around Total Knee Arthroplasty
Clin Orthop Relat Res 2001;392:131-
138.
54. Lewis P, Rorabeck CH, Bourne RB,
Devane P: Posteromedial tibial poly-
ethylene failure in total knee replace-
ments. Clin Orthop Relat Res 1994;
299:11-17.
55. Berend ME, Ritter MA, Meding JB, et
al: Tibial component failure mecha-
nisms in total knee arthroplasty.
Clin Orthop Relat Res 2004;428:26-
34.
56. Dennis DA, Komistek RD, Colwell
CE Jr, et al: In vivo anteroposterior
femorotibial translation of total knee
arthroplasty: A multicenter analysis.
Clin Orthop Relat Res 1998;356:47-
57.
57. Komistek RD, Scott RD, Dennis DA,
Yasgur D, Anderson DT, Hajner ME:
In vivo comparison of femorotibial
contact positions for press-fit posteri-
or stabilized and posterior cruciate-
retaining total knee arthroplasties.
J Arthroplasty 2002;17:209-216.
58. Plante-Bordeneuve P, Freeman MA:
Tibial high-density polyethylene
wear in conforming tibiofemoral
prostheses. J Bone Joint Surg Br 1993;
75:630-636.
59. Puloski SK, McCalden RW, Mac-
Donald SJ, Rorabeck CH, Bourne RB:
Tibial post wear in posterior stabi-
lized total knee arthroplasty: An un-
recognized source of polyethylene de-
bris. J Bone Joint Surg Am 2001;83:
390-397.
60. Mikulak SA, Mahoney OM, dela Rosa
MA, Schmalzried TP: Loosening and
osteolysis with the press-fit condylar
posterior-cruciate-substituting total
knee replacement. J Bone Joint Surg
Am 2001;83:398-403.
61. Callaghan JJ, O’Rourke MR, Goetz
DD, Schmalzried TP, Campbell PA,
Johnston RC: Tibial post impinge-
ment in posterior-stabilized total
knee arthroplasty. Clin Orthop Relat
Res 2002;404:83-88.
62. Mauerhan DR: Fracture of the poly-
ethylene tibial post in a posterior
cruciate-substituting total knee ar-
throplasty mimicking patellar clunk
64
syndrome: A report of 5 cases.
J Arthroplasty 2003;18:942-945.
63. Kilgus DJ: Polyethylene wear in mobile-
bearing prostheses.Orthopedics 2002;
25(2 suppl):S227-S233.
64. Kaper BP, Smith PN, Bourne RB, Rora-
beck CH, Robertson D: Medium-term
results of a mobile bearing total knee
replacement. Clin Orthop Relat Res
1999;367:201-209.
65. Buechel FF Sr: Long-term followup af-
ter mobile-bearing total knee replace-
ment. Clin Orthop Relat Res 2002;
404:40-50.
66. Udomkiat P, Dorr LD, Long W:
Matched-pair analysis of all-polyeth-
ylene versus metal-backed tibial com-
ponents. J Arthroplasty 2001;16:689-
696.
67. Najibi S, Iorio R, Surdam JW, Whang
W, Appleby D, Healy WL: All-
polyethylene and metal-backed tibial
components in total knee arthroplas-
ty: A matched pair analysis of func-
tional outcome. J Arthroplasty 2003;
18:9-15.
68. Brassard MF, Insall JN, Scuderi GR,
Colizza W: Does modularity affect
clinical success? A comparison with a
minimum 10-year followup. Clin
Orthop Relat Res 2001;388:26-32.
69. Rand JA, Trousdale RT, Ilstrup DM,
Harmsen WS: Factors affecting the
durability of primary total knee pros-
theses. J Bone Joint Surg Am 2003;
85:259-265.
70. Lancaster JG, Dowson D, Isaac GH,
Fisher J: The wear of ultra-high molec-
ular weight polyethylene sliding on
metallic and ceramic counterfaces
representative of current femoral sur-
faces in joint replacement. Proc Inst
Mech Eng [H] 1997;211:17-24.
71. Puloski SK, McCalden RW, Mac-
Donald SJ, Bourne RB, Rorabeck CH:
Surface analysis of posterior stabi-
lized femoral components used in to-
tal knee arthroplasty. J Arthroplasty
2003;18:822-826.
72. Wasielewski RC, Galante JO, Leighty
RM, Natarajan RN, Rosenberg AG:
Wear patterns on retrieved polyethy-
lene tibial inserts and their relation-
Journal of the American Academy of Orthopaedic Surgeons
ship to technical considerations dur-
ing total knee arthroplasty. Clin
Orthop Relat Res 1994;299:31-43.
73. Collier MB, Jewett BA, Engh CA Jr:
Clinical assessment of tibial polyeth-
ylene thickness: Comparison of radio-
graphic measurements with as-im-
planted and as-retrieved thicknesses.
J Arthroplasty 2003;18:860-866.
74. Fukuoka Y, Hoshino A, Ishida A: A
simple radiographic measurement
method for polyethylene wear in total
knee arthroplasty. IEEE Trans
Rehabil Eng 1999;7:228-233.
75. Short A, Gill HS, Marks B, et al: A nov-
el method for in vivo knee prosthesis
wear measurement. J Biomech 2005;
38:315-322.
76. Cadambi A, Engh GA, Dwyer KA,
Vinh TA: Osteolysis of the distal fe-
mur after total knee arthroplasty.
J Arthroplasty 1994;9:579-594.
77. Nadaud MC, Fehring TK, Fehring K:
Underestimation of osteolysis in pos-
terior stabilized total knee arthroplas-
ty. J Arthroplasty 2004;19:110-115.
78. Berry DJ: Recognizing and identifying
osteolysis around total knee arthro-
plasty. Instr Course Lect 2004;53:
261-264.
79. Benevenia J, Lee FY, Buechel F, Par-
sons JR: Pathologic supracondylar
fracture due to osteolytic pseudotu-
mor of knee following cementless
total knee replacement. J Biomed
Mater Res 1998;43:473-477.
80. Huang CH, Yang CY, Cheng CK: Frac-
ture of the femoral component associ-
ated with polyethylene wear and os-
teolysis after total knee arthroplasty.
J Arthroplasty 1999;14:375-379.
81. Engh GA, Herzwurm PJ, Parks NL:
Treatment of major defects of bone
with bulk allografts and stemmed
components during total knee arthro-
plasty. J Bone Joint Surg Am 1997;79:
1030-1039.
82. Engh GA, Koralewicz LM, Pereles TR:
Clinical results of modular polyethy-
lene insert exchange with retention of
total knee arthroplasty components.
J Bone Joint Surg Am 2000;82:516-
523.