 KNEE

Reliable outcomes and survivorship

of ­primary total knee arthroplasty for
­osteonecrosis of the knee

B. P. Chalmers, Aims
K. G. Mehrotra, Knee osteonecrosis in advanced stages may lead to joint degeneration. Total knee
R. J. Sierra, arthroplasty (TKA) for osteonecrosis has traditionally been associated with suboptimal
M. W. Pagnano, results. We analyzed outcomes of contemporary TKAs for osteonecrosis, with particular
M. J. Taunton, emphasis on: survivorship free from aseptic loosening, any revision, and any reoperation
M. P. Abdel plus the clinical outcomes, complications, and radiological results.

Mayo Clinic, Patients and Methods

Rochester, Minnesota,
United States
In total, 156 patients undergoing 167 primary TKAs performed for osteonecrosis between
2004 and 2014 at a single institution were reviewed. The mean age at index TKA was 61
years (14 to 93) and the mean body mass index (BMI) was 30 kg/m2 (18 to 51) The mean
follow-up was six years (2 to 12). A total of 110 TKAs (66%) were performed for primary
osteonecrosis and 57 TKAs (34%) for secondary osteonecrosis. Overall, 15 TKAs (9%) had
tibial stems, while 12 TKAs (7%) had femoral stems. Posterior-stabilized designs were used
in 147 TKAs (88%) of TKAs. Bivariate Cox regression analysis was conducted to identify risk
factors for revision and reoperation.

Results
Survivorship free from aseptic loosening, any revision, and any reoperation at ten
years was 97% (95% confidence interval (CI) 93 to 100), 93% (95% CI 85 to 100), and
82% (95% CI 69 to 93), respectively. No factors, including age, sex, BMI, primary versus
secondary osteonecrosis, stem utilization, and constraint, were identified as risk
factors for reoperation. Four TKAs (2%) underwent revision, most commonly for tibial
aseptic loosening (n = 2). Excluding revisions and reoperations, there was a total of 11
complications (7%), with the most common being a manipulation under anaesthesia (six
TKAs, 4%). Mean Knee Society Scores (Knee component) significantly improved from 57
(32 to 87) preoperatively to 91 (49 to 100) postoperatively (p < 0.001). No unrevised TKAs
had complete radiolucent lines or radiological evidence of loosening.

Conclusion
Contemporary cemented TKAs with selective stem utilization for osteonecrosis resulted
in durable survivorship, a low complication rate, and reliable improvement in clinical
outcomes.
Cite this article: Bone Joint J 2019;101-B:1356–1361.

Correspondence should be
sent to M. P. Abdel; email:
abdel.matthew@mayo.edu
©2019 The British Editorial
Society of Bone & Joint Surgery
doi:10.1302/0301-620X.101B11.
BJJ-2019-0576.R1 $2.00
Bone Joint J
2019;101-B:1356–1361.
Osteonecrosis can develop in the knee as a result
of disrupted vascular supply, causing periarticu-
lar bone and cartilage necrosis.1-10 The aetiology
can be primary (idiopathic) or secondary to a
known clinical entity, which includes excessive
alcohol use, prolonged corticosteroid use, radia-
tion, sickle cell anaemia, and other inflammatory
conditions.1-10 Osteonecrosis, when it occurs in
the knee, can be painful and may lead to pro-
gressive cartilage loss and joint degeneration and
deformity.4-6
When joint degeneration progresses to end-
stage arthritic changes and nonoperative and joint-­
preserving modalities fail, arthroplasty options are
often considered.10-15 In patients with this pathol-
ogy, implant fixation is a concern due to bone
necrosis and bone loss secondary to the underly-
ing pathological process. Previous studies have
reported concerning rates of aseptic loosening,12-14
with few studies analyzing either mid-term or long-
term the results of contemporary cemented total
knee arthroplasty (TKA) for knee osteonecrosis.15

1356 THE BONE & JOINT JOURNAL

 Reliable outcomes and survivorship of ­primary total knee arthroplasty for ­osteonecrosis of the knee1357
The purpose of this study was to analyze the midterm out-
comes of contemporary cemented TKAs in a large number of
patients with primary and secondary knee osteonecrosis, with
particular emphasis on: 1) survivorship free from aseptic loos-
ening, any revision, and any reoperation; 2) complications;
3) clinical outcomes; and 4) radiological results.
Patients and Methods
We retrospectively reviewed all patients who underwent a pri-
mary TKA for knee osteonecrosis at a single academic institu-
tion between 2004 and 2014 by examining an institutional total
joint registry (TJR) of prospectively collected data. Patients are
routinely evaluated with examination, radiographs, and clini-
cal outcome measures postoperatively at three months, one
year, two years, five years, and subsequent five-year intervals.
Patients were followed until death, revision, or final clinical
follow-up at a minimum of two years. Clinical outcome scores
were analyzed measuring Knee Society Scores (KSS).16 Radio-
logical review was performed by two authors (BPC and MPA)
to evaluate for implant loosening at a minimum follow-up of
two years; the presence of a complete progressive radiolu-
cent line of ≥ 2 mm defined an implant as being radiologically
loose.17 Institutional review board approval was obtained from
the Mayo Clinic (Rochester, Minnesota, United States) prior to
beginning the study.
Patients. In total, 161 patients (173 TKAs) who underwent
TKA for primary or secondary knee osteonecrosis were iden-
tified for review. These patients comprised 1.1% (173/15 720)
of primary TKAs performed at our institution during the same
time period. Two patients (two TKAs) were lost to follow-up
and three patients (four TKAs) died prior to minimum two-year
follow-up due to causes unrelated to the primary TKA. There-
fore, 156 patients (167 TKAs) were included for a­ nalysis at
a mean follow-up from surgery of six years (2 to 12). In this
study, all patients had at least two years of follow-up; 102
TKAs (61%) had at least five years of follow-up and 34 TKAs
(20%) had at least ten years of follow-up. Demographic data
are listed in Table I. In total, 110 TKAs (66%) were performed
for primary osteonecrosis (Fig. 1), while 57 TKAs (34%) were
performed for secondary osteonecrosis (Fig. 2). Causes of sec-
ondary osteonecrosis included: steroid-induced, post-traumatic,
alcohol-induced, and radiation-induced (Table I). MRI of the
knee was not routinely performed. Prior operations occurred in
52 knees (31%), including: arthroscopic cartilage or meniscal
procedures (n = 35, 21%), open reduction and internal fixation
(ORIF) for fractures in patients who developed post-traumatic
osteonecrosis (n = 8, 5%), core decompressions (n = 7, 4.5%),
and allograft cartilage transfers in combination with a periar-
ticular osteotomy (n = 2, 1.2%).
Surgical characteristics. All TKAs were performed at a sin-
gle academic institution by multiple surgeons experienced in
complex primary and revision TKAs. All TKAs were cemented,
with routine use of antibiotic cement. A rapid recovery postop-
erative rehabilitation protocol was standardized between all sur-
geons. Implant systems included: PFC Sigma (DePuy, Warsaw,
Indiana; 83 TKAs, 50%), NexGen (Zimmer, Warsaw, Indiana;
36 TKAs, 22%), Triathalon (Stryker, Mahwah, New Jersey;
33 TKAs, 20%), Persona (Zimmer; seven TKAs, 4.2%), MBT
VOL. 101-B, No. 11, NOVEMBER 2019
Table I. Patient demographics
Demographic Data
Patients, n 156
Total knee arthroplasties, n 167
Sex, female, n (%) 90 (58)
Mean age, yrs (range) 61 (14 to 93)
Mean body mass index, kg/m2 (range) 30 (18 to 51)
Primary knee osteonecrosis, n (%) 110 (66)
Secondary knee osteonecrosis, n (%) 57 (34)
Steroid-induced, n (%) 41 (25)
Post-traumatic, n (%) 8 (5)
Alcohol-induced, n (%) 4 (2)
Radiation-induced, n (%) 4 (2)
Mean follow-up, yrs (range) 6 (2 to 12)
Revision System (DePuy; seven TKAs, 4.2%), and Genesis II
(Smith & Nephew, Memphis, Tennessee; one TKA, 1%). Pos-
terior-stabilized (PS) designs were utilized in 147 TKAs (88%);
14 TKAs (8%) had cruciate-retaining (CR) designs and six
TKAs (4%) had varus-valgus constraint (VVC). Modular tib-
ial stems were implanted in 15 TKAs (9%); modular cemented
femoral stems were used in 12 TKAs (7%). There was no differ-
ence in rate of tibial stem usage between primary and secondary
osteonecrosis cases, but there were significantly more femoral
stems implanted for secondary osteonecrosis (n = 9, 16%) com-
pared with primary osteonecrosis (n = 3, 3%; p = 0.003, Fisher’s
exact test). While stem usage was directed mainly by experi-
enced surgeon judgement, all knees with tibial stems and 10/12
knees with femoral stems had metaphyseal extension of the
osteonecrotic lesions seen on plain radiographs. The remaining
two femoral stems were used to bypass existing hardware in the
distal femur.
Statistical analysis. All data are presented as means with
ranges. Unpaired Student’s t-tests were undertaken to analyze
all continuous variables and Fisher’s exact square tests were
used to compare all dichotomous variables. Kaplan–Meier
curves18 were constructed with 95% confidence intervals (CIs)
to present estimated survivorship free from aseptic loosening,
any revision, and any reoperation. Bivariable Cox regression
analysis was performed to calculate hazard ratios (HRs) with
95% CIs to identify risk factors of poorer survival free of any
revision and any reoperation. Statistical significance was set at
a p-value < 0.05.
Results
Survivorship. Estimated survivorship free from aseptic loosen-
ing was 99% (95% CI 98 to 100) and 97% (95% CI 93 to 100) at
five and ten years, respectively (Fig. 3; Table II). Estimated sur-
vivorship free from any revision was 98% (95% CI 96 to 100)
and 93% (95% CI 85 to 100) at five and ten years, respectively
(Fig. 4; Table II); there was no significant difference of ten-year
revision-free survival in patients with primary osteonecrosis
(91%; 95% CI 81 to 99) and secondary osteonecrosis (94%;
95% CI 84 to 99; p = 0.7, Cox regression analysis). Estimated
survivorship free from any reoperation was 92% (95% CI 86 to
96) and 82% (95% CI 69 to 93) at five and ten years, respec-
tively. There was no difference in bivariable Cox regression
1358 B. P. Chalmers, K. G. Mehrotra, R. J. Sierra, M. W. Pagnano, M. J. Taunton, M. P. Abdel 

Fig. 1a Fig. 1b Fig. 1c Fig. 1d

a) Anteroposterior and b) lateral radiographs of a 70-year-old female patient who developed progressive lateral femoral condyle primary, atraumatic
osteonecrosis, and joint collapse that failed conservative management. c) and d) She underwent cemented nonconstrained total knee arthroplasty
and did well with radiologically stable implants at seven years.

Fig. 2a Fig. 2b Fig. 2c Fig. 2d

a) Anteroposterior and b) lateral radiographs of a 52-year-old female patient who developed extensive osteonecrosis of her femoral condyles and
lateral tibial plateau with femoral and tibial extension into her metaphysis secondary to high corticosteroid use for lymphoma treatment. c) and
d) She underwent posterior-stabilized total knee arthroplasty with cemented femoral and tibial stems; she did well with stable implants at six years’
follow-up.

analysis and did not identify any risk factors for poorer survival
free from revision or reoperation. The risk factors analyzed
included age, sex, body mass index (BMI), primary versus sec-
ondary osteonecrosis, level of constraint, or stem usage (p > 0.1
for all).
Four TKAs (2.4%) underwent implant revision during the
study period: two TKAs (1.2%) for tibial aseptic loosening (one
at three years and one at five years), one TKA (0.6%) for global
instability at five years postoperatively, and one TKA (0.6%)
for a two-stage exchange for deep infection at six months post-
operatively. One of these patients, revised for tibial aseptic
loosening, had secondary knee osteonecrosis prior to TKA. A
total of 11 TKAs (7%) underwent reoperation without implant
revision (Table III).
Complications. Perioperative complications, excluding revi-
sions and reoperations, occurred in 11 knees (7%), including
six manipulations under anaesthesia for postoperative stiffness
(3.7%). Three patients (1.9%) developed postoperative venous
thromboembolism (one pulmonary embolism and two deep
venous thromboses) that were treated medically with anticoag-
ulation. One patient (0.6%) had an intraoperative partial patellar
tendon avulsion that occurred during trialling; this was repaired
at the time of TKA without extensor mechanism disruption or
lag at final follow-up. Finally, one patient had delayed wound
healing and prolonged drainage that was treated with dressing
changes and suppressive antibiotics (0.6%); this healed without
development of prosthetic joint infection (PJI).
Clinical outcomes. Knee Society Scores (Knee component)
significantly improved from a mean of 57 (32 to 87) preopera-
tively to a mean of 91 (49 to 100) postoperatively (p < 0.001,
Student’s t-test). The mean improvement in KSS was 32
(3 to 65). There was no significant difference in KSS between
patients treated for primary (mean KSS = 92) and secondary
(mean KSS = 89) knee osteonecrosis (p = 0.2, Student’s t-test).
Radiological outcomes. On final radiological evaluation of
unrevised TKAs, there were seven TKAs (4%) that exhibited
nonprogressive radiolucent lines around the tibial component.
There were also two TKAs (1%) that had nonprogressive

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 Reliable outcomes and survivorship of ­primary total knee arthroplasty for ­osteonecrosis of the knee1359

Fig. 3

Kaplan–Meier survivorship curve depicting survivorship free from a

­ septic loosening of 97% at
ten years with 95% confidence intervals.

Table II. Results of total knee arthroplasty for knee osteonecrosis

Result Value
Survivorship free from aseptic loosening at 10 yrs, % (95% CI) 97 (93 to 100)
Survivorship free from revision, at 10 yrs, % (95% CI) 93 (85 to 100)
Survivorship free from any reoperation at 10 yrs, % (95% CI) 82 (69 to 93)
Revisions, n (%) 4 (2.4)
Reoperations, n (%) 11 (7)
Complications, excluding revisions and reoperations, n (%) 11 (7)
Mean preoperative Knee Society Score, Knee component (range) 57 (32 to 87)
Mean postoperative Knee Society Score, Knee component (range) 91 (49 to 100)
CI, confidence interval

radiolucent lines around the femoral component. Only two of
those were seen in the same location as the osteonecrosis pre-
operatively, which was in the lateral tibial plateau in one and the
medial femoral condyle in another. No TKAs had evidence of
definitive component loosening as previously defined.17
Discussion
In the current study, the largest contemporary study of cemented
TKA for knee osteonecrosis to the authors’ knowledge, there
was excellent implant durability with 97% (95% CI 93 to 100)
survivorship free from aseptic loosening at ten years, with no
radiological evidence of loosening at midterm follow-up. Fur-
thermore, there was a low overall revision rate and complica-
tion rate with a reliable improvement in clinical outcomes.
Nonhinged cemented TKA with selective use of stems results
in excellent midterm implant fixation, with a ten-year survivor-
ship free from aseptic loosening of 97% and no radiological
evidence of loosening at a mean of five years. A previous study
reported a high failure rate from aseptic loosening, especially
with cementless components.13 Mont et al13 reported a near 40%
revision rate for aseptic loosening in a small series of TKAs per-
formed in the 1980s for corticosteroid-induced osteonecrosis,
using mainly unstemmed cementless implants. Two prior stud-
ies reviewing TKAs12,14, from the same time period, reported
an approximately 85% five-year survivorship free for primary
VOL. 101-B, No. 11, NOVEMBER 2019
TKAs performed for osteonecrosis. Contemporary results, sim-
ilar to this study, of cemented TKAs with selective use of stems
in knees with metaphyseal extension of bony necrosis have
shown excellent results.15 Mont et al15 reported no revisions for
aseptic loosening and no radiological evidence of loosening at
a mean follow-up of nine years in 32 TKAs performed for knee
osteonecrosis. In that study and the current study, stems were
added when there was significant metaphyseal extension of the
bony necrosis and were more common in cases of secondary
osteonecrosis in our study (16% vs 5% for primary osteonecro-
sis). Nonhinged, cemented condylar knee designs with selective
use of stems demonstrate durable implant survivorship without
radiological signs of loosening in contemporary TKA for knee
osteonecrosis.
The overall revision rate was low in this series (2%) and at
a mean follow-up of six years, we noted a modest reoperation
rate particularly for periprosthetic femoral fractures. Two of the
patients with periprosthetic fracture had primary and two patients
had secondary osteonecrosis; none had metaphyseal extension
of their osteonecrosis or required stem fixation. In addition, two
of these fractures were diaphyseal. We have concluded that this
modest rate of periprosthetic femoral fractures is unlikely to be
related to their underlying diagnosis of osteonecrosis. At a mean
follow-up of nine years, Mont et al15 reported one revision for
flexion instability in 32 cemented TKAs for knee osteonecrosis.
1360 B. P. Chalmers, K. G. Mehrotra, R. J. Sierra, M. W. Pagnano, M. J. Taunton, M. P. Abdel 

Fig. 4

Kaplan–Meier survivorship curve depicting survivorship free from any revision of 93% at ten
years with 95% confidence intervals.

Table III. Reoperations

Reoperation n (%)
Open reduction and internal fixation for periprosthetic femoral fractures 4 (2)
Postoperative haematoma evacuation 3 (2)
Irrigation, debridement, and component retention for acute postoperative prosthetic 2 (1)
joint infection
Extensor mechanism reconstruction for traumatic patella fracture at 1.5 years 1 (0.5)
Acute postoperative superficial wound revision 1 (0.5)

In a systematic review, Myers et al11 reported a 0% revision
rate of TKAs performed for primary osteonecrosis and a 3%
revision rate when performed for secondary osteonecrosis after
1985. We have previously reported a significantly lower sur-
vivorship in patients with secondary compared with primary
osteonecrosis undergoing unicompartmental knee arthroplasty
(UKA),19 In the current study, we found no differences in revi-
sion rates between these groups of patients undergoing TKA.
TKA for osteonecrosis resulted in a low revision rate at midterm
follow-up in the current series, the largest contemporary series
of cemented TKA for osteonecrosis to date. These revision rates
are comparable with contemporary revision rates of TKA for
osteoarthritis.20-22
Osteonecrosis not only leads to pain, but also progressive
joint degeneration and collapse in all of the patients in this
series. The mean improvement in KSS (Knee component) was
35 points, with a final KSS of 91 points, in the ‘excellent’ range.
Mont et al15 similarly reported excellent functional outcomes in
31/32 patients undergoing cemented TKA for knee osteonecro-
sis. The functional outcomes and improvement compare with
results obtained for patients undergoing TKA for osteoarthritis
at mid-to-long-term follow-up.20-24
We acknowledge several limitations to the current study.
First, due to the retrospective design, not all patients were
treated in the same manner (stems, implant choice, constraint,
etc.). Furthermore, all cases were performed at a single tertiary
referral academic centre by surgeons experienced in complex
primary and revision TKA, which may limit generalizability.
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In addition, this is a relatively small cohort with even fewer
patients undergoing revision (n = 4). Therefore, it was difficult
to statistically identify any risk factors for failure. However,
TKA for knee osteonecrosis is relatively uncommon, compris-
ing approximately 1% of all the TKAs performed at our institu-
tion during the study period.
In this large contemporary cohort of TKAs performed for
knee osteonecrosis, nonconstrained cemented TKAs with selec-
tive use of stems in patients with either primary or secondary
knee osteonecrosis resulted in durable implant survivorship at
midterm follow-up. The survivorship free from aseptic loosening
and any revision was 97% (95% CI 93 to 100) and 93% (95% CI
85 to 100), respectively, at ten years; further, no TKAs were radi-
ologically loose. There was a moderate complication rate and
reliable improvement in clinical outcomes. The excellent out-
comes of contemporary TKA for knee osteonecrosis reported in
this study approach those of primary TKA for osteoarthritis.20-24
Take home message
- Contemporary nonconstrained total knee arthroplasty is a
durable option for patients with primary and secondary os-
teonecrosis, with a 97% and 93% survivorship free of aseptic
loosening and any revision, respectively, at ten years.
- Patients with primary or secondary osteonecrosis undergoing contem-
porary total knee arthroplasty have a reliable improvement in clinical out-
come scores with a modest complication rate.
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 Reliable outcomes and survivorship of ­primary total knee arthroplasty for ­osteonecrosis of the knee1361
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Author information:
B. P. Chalmers, MD, Orthopedic Surgery Resident
K. G. Mehrotra, MD, Orthopedic Surgery Resident
R. J. Sierra, MD, Professor of Orthopedic Surgery
M. W. Pagnano, MD, Professor of Orthopedic Surgery
M. J. Taunton, MD, Associate Professor of Orthopedic Surgery
M. P. Abdel, MD, Professor of Orthopedic Surgery
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota,
USA.
Author contributions:
B. P. Chalmers: Designed and conceptualized the study, Collected and
analyzed the data, Wrote the manuscript.
K. G. Mehrotra: Designed and conceptualized the study, Collected and
analyzed the data, Wrote the manuscript.
R. J. Sierra: Wrote the manuscript.
M. W. Pagnano: Designed and conceptualized the study, Wrote the
manuscript.
M. J. Taunton: Designed and conceptualized the study, Wrote the
manuscript.
M. P. Abdel: Designed and conceptualized the study, Analyzed the data,
Wrote the manuscript.
Funding statement:
The author or one or more of the authors have received or will receive
benefits for personal or professional use from a commercial party related
directly or indirectly to the subject of this article. In addition, benefits
have been or will be directed to a research fund, foundation, educational
institution, or other nonprofit organization with which one or more of the
authors are associated.
ICMJE COI statement:
R. J. Sierra reports royalties from Zimmer Biomet, not related to this study.
M. W. Pagnano reports royalties from DePuy Synthes and Stryker, not
related to this study. M. P. Abdel reports consultancy fees and royalties from
Stryker, not related to this study.
Ethical review statement:
This study was approved prior to initiation by the Institutional Review Board:
Mayo Clinic Rochester IRB# 16-005989.
This article was primary edited by P. Walmsley and first proof edited by
G. Scott