The Journal of Arthroplasty Vol. 22 No. 6 Suppl.

2 2007

Cemented Total Knee Arthroplasty Using a Modern

Prosthesis in Young Patients With Osteoarthritis

Gavan P. Duffy, MD,* Amy R. Crowder, MD,y

Robert R. Trousdale, MD,z and Daniel J. Berry, MDz

Abstract: Fifty-two consecutive cemented total knee arthroplasties were performed

using the Press-Fit Condylar (DePuy, Warsaw, Ind) knee system on patients aged
55 years or younger at Mayo Clinic Rochester from 1988 to 1994. Patients were
followed for a minimum of 10 years, with an average follow-up of 12 years (range,
10-15 years). There were 8 total revisions (15%), including 2 revisions before
10 years, one for sepsis at 1 year, and one for instability at 8 years. Six revisions
occurred between 10 and 15 years, all associated with polyethylene wear and
osteolysis. Implant survival rate was estimated to be 96% at 10 years and 85% at
15 years of follow-up. Key words: total knee arthroplasty, cemented, young patients
with osteoarthritis, long-term results.
© 2007 Elsevier Inc. All rights reserved.

Total knee arthroplasty (TKA) has proven long-term
clinical success in elderly patients [1-4]. Reports by various
authors indicate very good intermediate results in
younger, more active patients using various knee designs
[5-8]. The longevity of total knees in young patients with
rheumatoid arthritis has been reported to be excellent [9].
Although these outcomes in young patients are encoura-
ging, concerns remain over the use of TKA in active
patients particularly into the second decade of use. We
report on the long-term survival of a primary cemented
cruciate-retaining TKA using the Press-Fit Condylar
(DePuy Orthopedics, Inc, Warsaw, Ind) knee system in a
young, active population with osteoarthritis.
Materials and Methods
The criteria for inclusion in the study were as follows:
(1) aged 55 years or younger at index arthroplasty; (2)
diagnosis of osteoarthritis or posttraumatic osteoarthritis;
From *Heekin Orthopaedics, Jacksonville, Florida; ythe Department
of Family Practice, Mayo Clinic, Jacksonville, Florida; and zthe
Department of Orthopedics, Mayo Clinic, Rochester, Minnesota.
Submitted February 9, 2007; accepted May 1, 2007.
No benefits or funds were received in support of the study.
Reprint requests: Gavan P. Duffy, MD, Heekin/Deshmukh
Orthopaedics, 1522 Oak St, Jacksonville, FL 32204.
© 2007 Elsevier Inc. All rights reserved.
0883-5403/07/1906-0004$32.00/0
doi:10.1016/j.arth.2007.05.001
(3) Press-Fit Condylar knee system prosthesis; (4) mini-
mum follow-up of 10 years; (5) cemented femoral, tibial,
and patellar component; (6) cruciate-retaining design; and
(7) modular tibial component.
At the Mayo Clinic Rochester, Minnesota, between 1987
and 1994, 52 consecutive primary TKAs were performed in
42 patients with osteoarthritis who met the inclusion
criteria. The median length of follow-up was 12 years
(range, 10-17 years).
There were 18 men and 24 women. The median age
was 53 years (range, 29-55 years). There were 17 right, 15
left, and 10 bilateral procedures. The mean weight of the
patients was 75 kg for the women and 95 kg for the men.
The mean height was 158 cm for the women and 178 cm
for the men. The mean body mass index for both women
and men was 30.0.
The preoperative diagnosis was osteoarthritis in all 52
knees. Twenty-eight knees had previous surgeries per-
formed including 8 arthroscopic debridements, 7 upper
tibial osteotomies, 6 open debridements, 2 open reduction
and internal fixation femurs, 2 open reduction and internal
fixation tibiae, 1 patellectomy, 1 distal femur osteotomy,
and 1 anterior cruciate ligament reconstruction.
Clinical and radiographic evaluations were performed
before surgery; at 1, 5, and 10 years; and at latest follow-
up. Latest follow-up consisted of clinical examination in
23 patients (44%), phone interview in 4 patients (8%),
and detailed mail questionnaire in 25 patients (48%). Fifty
knee arthroplasties had follow-up radiographs available

67
68 The Journal of Arthroplasty Vol. 22 No. 6 Suppl. 2 September 2007

function score improved from 40 to 86 points at latest

follow-up.
There were 8 revisions during the entire follow-up
period . Two revisions occurred before 10 years, one for
sepsis at 1 year, and one for instability at 8 years. Six
revisions occurred after 10 years of follow-up. Three
revisions were for femoral loosening, polyethylene wear,
and osteolysis (Fig. 1); 2 revisions occurred at 11 years and
12 years, respectively, for polyethylene wear. One
revision occurred at 11 years for tibial tray fracture,
polyethylene wear, and osteolysis of both the tibial and
femoral components (Fig. 2).
The Kaplan-Meier estimated survival rate to revision
was estimated to be 96% at 10 years and 85% at 15 years
(Fig. 3).

Radiographic Results

At an average of 8 years of radiographic follow-up

Fig. 1. Radiograph of a failed total knee with polyethylene
wear and femoral osteoarthritis.
(range, 2-15 years), there were 2 knees with radiographic
evidence of loosening, one with a 2-mm complete
radiolucent lines in area 1 on both the tibia and femur
and one radiographically failed femoral component with a
2-mm complete radiolucent lines between the component
and the cement around the entire component.

for review at a median of 8 years from surgery. Two

patients only had 2-year radiographic follow-up available
Discussion
at 12 years, but had clinical follow up.
Knee scores were calculated with the system estab- During the past 25 years, TKA has demonstrated
lished by the Knee Society [10]. Two separate scores were reliable, durable pain relief; deformity correction; and
tabulated including the functional score for walking, stair functional improvement for patients with knee arthritis of
climbing, and use of walking aids and the knee score for varied etiologies [4,14]. Good results have increased the
pain, range of motion, and stability. All patients received demand for the operation by patients of all ages; and
similar supervised perioperative and postoperative care concern remains over the possibility of increased failure
including 24-hour perioperative antibiotics, thromboem-
bolic prophylaxis with coumadin (Dupont Pharmaceuti-
cals, Wilmington, Del), and early mobilization.
Radiographic results were assessed according to the
Knee Society radiographic evaluation system [11]. Pre-
operative standing knee radiographs were used to
determine mechanical alignment. Postoperative radio-
graphs consisting of anteroposterior and lateral views
were evaluated for femoral and tibial component position,
alignment, and presence or progression of radiolucent
lines at the bone-cement and prosthesis-cement interfaces
according to the Knee Society guidelines [11].
Statistical analysis was performed using the 2-sample
test or Wilcoxon rank sum test for comparison of
continuous variables. Changes in the continuous variables
were assessed using the paired t tests or signed rank test.
Comparison of proportions between groups was made
with χ2 test. Kaplan-Meier analysis of implant survival is
also reported [12,13].

Results

The knee score improved from an average of 36 points Fig. 2. Radiograph of failed total knee with polyethylene
preoperatively to 92 points at latest follow-up. The wear, osteolysis, and tibial tray fracture.
 Cemented TKA Using a Modern Prosthesis in Young Patients With Osteoarthritis  Duffy et al
Fig. 3. Kaplan-Meier survivorship of implant survival
for revision.
rates in younger, more active patients. Component
loosening, polyethylene wear, and bone loss, as well as
the increased complications seen in revision TKA, have
discouraged the widespread use of TKA in younger, active
patients [15]. The results of early and intermediate studies
have not had significant failure rates from aseptic loosen-
ing or component wear; and similarly, longer-term results
in young patients have been encouraging [6,8,15,16].
Dalury et al [6] reviewed 103 cemented TKAs in
patients younger than 45 years. At an average follow-up
period of 7.2 years, there were no revisions for aseptic
loosening or wear. Notably, most patients (87%) in this
study had a preoperative diagnosis of rheumatoid arthritis
or juvenile rheumatoid arthritis.
Gill et al [16] reported on 68 cemented TKAs in
50 patients 55 years or younger, with only 1 revision for
aseptic loosening and 1 revision for infection in 9.9 years
of average follow-up.
Lonner et al [17] described results on 32 TKAs in
32 patients with osteoarthritis whose ages were less than
40 years at the time of surgery. When excluding patients
involved in worker's compensation cases, knee scores were
good or excellent in 91% of patients followed for an
average of 7.9 years. Three revisions were performed for
aseptic loosening, and one patient had radiographic failure.
The survival rate was 88% at 8 years. However, this was a
group of patients from many centers with many different
prostheses and both cementless and cemented fixation.
Recent studies published by Diduch et al [15] and
Hofmann et al [8] have provided more long-term data in
younger patients with osteoarthritis. Diduch et al reported
the results of 108 patients whose average was 51 years with
an overall prosthesis survival rate of 94% at 8 years of
follow-up. Hofmann et al described 75 cementless TKAs in
57 patients younger than 50 years. Most of the patients
(57%) had a preoperative diagnosis of osteoarthritis.
Average follow-up was 9 years and 3 months. There were
no revisions and no radiographic failures.
Schai et al reviewed 235 TKAs with the same design as
our study. They report a survival rate of 90% at 10 years.
The average age of their patients was 68 years [18]. In our
study with younger patients, the survival rate is lower at
85% at 15 years.
Parvici et al reviewed 25 TKAs in young patients (mean
age, 17 years) with juvenile rheumatoid arthritis. They
found a high complication rate in this group, but with
69
good functional outcomes [19]. Meding et al reviewed 220
primary TKAs in patients with rheumatoid arthritis. They
had a survival rate of 96.5% at 20 years [20]. More
recently, Duffy et al reviewed the long-term results in 32
patients (47 knees) younger than 55 years with rheuma-
toid arthritis. These patients have a survival rate of 93.7%
at 20 years [21].
The decision to proceed with TKA in the younger
patient is a difficult one. Nonoperative management
should be exhausted, and more conservative operative
management such as proximal tibial osteotomy may be
considered in patients with unicompartmental disease and
malalignment particularly those patients who wish to
continue activities that place high demands on the knee
joint. Patient satisfaction with this option, however, tends
to decline over time; and patients who have undergone
this procedure before TKA may be at higher risk of
complications with subsequent arthroplasty [22,23].
The strengths of this study are the long-term clinical
follow-up; the use of only one prosthesis in the study,
which limits variables inherent to the prosthesis; and the
diagnosis being limited to osteoarthritis. The weaknesses
are its retrospective nature; the lack of documentation of
the activity of the patients; the exclusion of other
prostheses used at the time; and the exclusion of patients
with other diagnoses such as rheumatoid arthritis, which
limited the number of cases available for review. The
discrepancy between the radiographic follow-up and
clinical follow-up is also a concern. This allows for the
possibility that a percentage of patients who are clinically
functioning well could have radiographic problems that
remain undetected.
The concern that long-term follow-up would reveal
revision rates similar to total hip arthroplasties [24] in
young patients with degenerative joint disease has not
been the case in our study group. In our current study
using a modern cemented prosthesis in the first decade of
use, most of the knees functioned well. Six of the 8
revisions in this group occurred in the second decade, and
these were associated with polyethylene wear and
osteolysis. The prevalence of osteolysis will need to be
followed and studied through the second decade, and with
continual radiographic review may lead to continued
long-term problems.
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