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5
large areas of necrotic bone remain following bone cuts
may have a negative impact on component xation.
Polymethylmethacrylate (PMMA), or bone cement,
is often used for xation of joint prostheses. Unlike
cementless methods which achieve xation through
bony ingrowth around the implant, cemented knee
arthroplasties utilize PMMA to ll the space between
the implant and the porous trabecular bone. While
cementless knee arthroplasties are gaining popularity,
they are usually considered in younger patients who typically have adequate bone stock and high metabolic
activity (Matassi etal. 2013). Osteonecrosis of the distal
femur is characterized by reduced bone quality.
> As a result, cemented TKA has been historically con-
sidered as the gold standard in the treatment of end-
stage osteonecrosis of the distal femur. However,
outcomes for both cemented and cementless TKA in
recent literature have been largely successful.
Thus, there are no special considerations regarding
xation methods for TKA in patients who have knee
osteonecrosis. In some cases, extensive necrotic bone,
particularly in the metaphyseal region, may necessitate a
stemmed femoral or tibial component. Quite often, the
bone is found to be amenable to cementless xation.
This is the senior author’s preferred method as it leads
to a less complicated revision surgery, if needed.
5.2 Case Examples
5.2.1 Case Report #1
A 64-year-old female with no history of previous trauma,
arthroscopic procedures, steroid use, or alcohol abuse
presented with a complaint of a 3-month history of left
knee pain without injury. She reported pain on the medial
aspect of the knee characterized by intermittent sharp
and dull pain, swelling, clicking, and diminished range of
motion. Due to the pain, the patient relies on a cane
when walking for extended distances. Acetaminophen
and ibuprofen have provided minimal relief.
Physical examination showed mild effusion of the
left knee with medial joint line and medial femoral condyle tenderness to palpation. Active range of motion
was 5–135°. All ligaments appeared stable with negative
ligamentous maneuvers. A negative Steinman test but
positive McMurray’s test with click was identied.
Standing anteroposterior, lateral, merchant, and 45°
posteroanterior standing X-rays revealed mild medial
joint space narrowing with an osteoarthritic classication of Kellgren and Lawrence Grade II/III.An irregularity of the medial femoral condyle was also identied
which may be due to osteochondral defect or osteonecrosis (.
Fig.5.1).
The patient was advised that symptoms appear to be
secondary to a combination of degenerative arthritis,
possible degenerative tear of the medial meniscus, and
an osteochondral defect of the medial femoral condyle.
An MRI was recommended followed by conservative
management with physical therapy and Naproxen
500mg twice daily for the interim.
MRI ndings revealed a complex tear and extrusion
of the medial meniscus with a multiloculated parameniscal cyst anterior to the anterior root of the medial
meniscus measuring 1.2×0.7cm. A 3.1×1.3cm area of
crescentic subchondral low signal was noted in the
weight-bearing aspect of the medial femoral condyle
with moderate surrounding marrow edema. In concordance with original X-rays, the hypodense signal most
likely represented SPONK.
After discussion of ndings with the patient, she preferred to follow conservative treatment due to mild
improvement with physical therapy and hesitancy
toward surgical intervention. The patient returned
2months later with increasing pain and difculty carrying out activities of daily living. Repeated radiographs
of the left knee revealed collapse of the subchondral
bone at the medial femoral condyle reective of Ficat
Stage IV osteonecrosis. Due to the progressive nature of
the disease, TKA was recommended for which the
patient agreed.
Intraoperatively, degenerative changes and depression of the cartilage were noted at the medial femoral
condyle. Subchondral bone softening was also identied. Complete excision of the lesion was obtained during resection of the distal femur during femoral implant
preparation. After determining that the femoral bone
stock was adequate, cementless prosthetic implants were
used. The patient has signicantly improved knee pain
and is able to carry out activities of daily living with
minimal to no assistance at 1-year follow-up.
5.2.2 Case Report #2
A 63-year-old female with past medical history signicant for systemic lupus erythematosus, obesity, primary
hyperparathyroidism, chronic obstructive pulmonary
disease, right knee arthroscopy for Grade III cartilage
degeneration 3years prior, and daily corticosteroid use
presented with worsening right knee pain. Physical exam
ndings show mild joint effusion of the right knee.
There is also right knee pain and crepitus with passive
range of motion. Tenderness was also elicited over the
anterior aspect of the knee upon palpation. Radiographic
imaging of the right knee demonstrated mild tricompartmental degeneration with an osteoarthritic classication of Kellgren–Lawrence Grade II/III.There was
minor narrowing of the joint spaces with no fracture or
insufciency noted. The patient’s symptoms were indica-
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H. S. Salem et al.
5
. Fig. 5.1 a Standing anteroposterior radiograph of the left knee with evidence of an osteonecrotic lesion in the medial femoral condyle
(white arrow). b Anteroposterior radiograph of the left knee after cementless TKA
tive of osteoarthritis. She then received a cortisone injection and conservative strategies including weight loss,
physical therapy, and over-the-counter non- steroidal
diminished bone quality with large areas of necrotic
bone remaining following the bone cuts, prompting
cemented xation of the tibial and femoral components.
anti-inammatory drugs were discussed and recommended.
The patient presented again 6months after the initial
5.3 Published Outcome Data
visit with progressively worsening right knee pain and
difculty carrying out activities of daily living without
assistance. Radiographic imaging demonstrated the evidence of patchy mineralization in the right femur and
tibia that was thought to be due to osteonecrosis
(. Fig. 5.2). An MRI was performed which revealed
extensive osteonecrosis involving the distal femur bone
marrow extending into the majority of the medial femoral condyle. There is also an irregular contour of the
subchondral bone plate which may be indicative of multiple areas of subchondral collapse. Osteonecrosis was
also identied in medial tibial plateau without evidence
of subchondral insufciency. Due to a combination of
extensive physical and radiographic ndings, a TKA
was performed. Intraoperative assessment revealed
Chalmers et al. (2019) reviewed 167 TKAs in 156
patients who had primary (66%) and secondary (34%)
knee osteonecrosis. Outcomes were assessed using Knee
Society scores and radiographs after a mean follow-up
of 6years (range, 2 to 12years) and mean patient age of
61 years (range, 14 to 93years). All TKAs were xed
with antibiotic cement. Stemmed tibial and femoral
components were used in 9% and 7% of cases, respectively. At 10-year follow-up, implant survivorship free
from aseptic loosening and any reoperation including
revision surgery was 97%. Two TKAs (1%) underwent
revision surgery for aseptic loosening of the tibial component. No unrevised TKAs demonstrated radiologic
evidence of loosening. The knee component of the KSS
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. Fig. 5.2 a Standing anteroposterior radiograph of the right knee
revealing patchy mineralization of the femur and tibia. b Coronal T2
MRI of the right knee demonstrating extensive necrosis of the prox-
improved from 57 points (range, 32 to 87 points) preoperatively to 91 points (range, 49 to 100 points) at nal
follow-up. The authors concluded that cemented TKA
with selective stem utilization resulted in durable survivorship and reliable improvement in patient-reported
outcomes for patients who have knee osteonecrosis.
In another study evaluating the outcomes of
cemented TKA for osteonecrosis, 32 knees in 30 patients
were evaluated after a mean follow-up period of
108months (range, 49 to 144months) (Mont etal. 2002).
Due to sufcient bone loss or osteonecrotic bone involving the metaphysis, a stemmed femoral component was
used in 6 knees and a stemmed tibial component was
used in 2 knees. The mean age at the time of arthroplasty
was 54years (range, 31 to 77years). Twenty-two patients
had corticosteroid-associated osteonecrosis and the
remaining 8 had SPONK. At nal follow-up, 31 of the
32 knees (97%) demonstrated successful clinical outcomes with a mean KSS of 95 points, improving from a
preoperative mean of 54 points. There was no radiologic
evidence of progressive radiolucency in any cases. Only
one unsuccessful clinical outcome was reported at 9-year
follow-up in a patient who was undergoing corticosteroid therapy for systemic lupus erythematosus.
imal tibia and distal femur extending into a majority of the medial
femoral condyle. c Anteroposterior radiograph of the left knee after
TKA with cemented xation
> The authors of this study concluded that cement xa-
tion should be used for TKA in patients who have
osteonecrosis, and that femoral and/or tibial stems
should be utilized when warranted.
Mont etal. (1997) reviewed 31 cementless TKAs in 21
patients under the age of 50 who had a diagnosis of corticosteroid-associated osteonecrosis of the knee. Clinical
and radiologic outcomes were reported after a mean 8.2year follow-up (range, 2 to 16years). The revision rate for
aseptic loosening was 37% (11 knees) and 3 additional
knees were revised for periprosthetic joint infection (PJI).
Of note, all 6 knees in patients who did not have systemic
lupus erythematosus (SLE) had excellent clinical results,
while only 11 of 25 knees (44%) were clinically successful
in patients who had SLE.While the results of this study
are not encouraging for the use of cementless TKA for
patients who have knee osteonecrosis, it is important to
consider that the technology used for the manufacturing
of cementless arthroplasty implants has improved considerably since this study was published in 1997. While
limited, there is evidence of improved outcomes in
patients who had osteonecrosis and underwent TKA
with newer generation cementless implants.
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H. S. Salem et al.
Sultan etal. (2018) evaluated 49 knees in 46 patients
5.4 Conclusion
who had osteonecrosis and underwent primary cementless TKA. The main outcomes of interest were implant
survivorship, clinical outcomes, complications, and
radiographic ndings after a mean follow-up of
44months (range, 36 to 96months). Implant survivorship free from aseptic loosening was 97.9% and all-cause
implant survivorship was 95.9%. In total, one knee was
revised for aseptic loosening and one knee was revised
for a PJI. The mean KSS pain score was 93 points
5
(range, 85 to 100 points) and the mean KSS function
score was 84 points (range, 70 to 90 points). Among the
cases that did not undergo revision surgery, no evidence
of progressive radiolucency, subsidence, or changes in
postoperative implant alignment were noted at nal follow- up.
TKA is the treatment of choice for patients who have
osteonecrosis of the knee with femoral condyle collapse and failure of conservative treatment. While earlier studies advise against the use of cementless xation
for TKA in the setting of osteonecrosis (Mont et al.
1997), it is important to note the advancements in tech-
nology with newer generation cementless implants may
have led to better outcomes (Sultan etal. 2018). Several
factors must be taken into account when selecting the
optimal xation method for TKA in patients who have
osteonecrosis. The overall quality of the distal femoral
and proximal tibial bone should be assessed intraoperatively. Gross examination of bone quality should be
evaluated and stability of the cementless xation be
ensured. If these factors are not determined to be opti-
> The results of this study indicate that excellent survi-
vorship and clinical outcomes can be achieved with
newer generation cementless xation of TKA in
patients who have osteonecrosis.
mal, cemented xation should be utilized. The use of
stemmed implants or bone grafts should be used judiciously for patients in whom large areas of necrosis
may compromise xation. Overall, the current literature has demonstrated acceptable outcomes of
Seldes etal. (1999) reviewed 31 TKAs in 24 patients
who had steroid-induced osteonecrosis of the knee.
cemented and cementless xation in appropriately
selected patients.
KSS was used to evaluate clinical outcomes and radiographs were evaluated for alignment and evidence of
subsidence or loosening after a mean follow-up time
of 64 months (range, 24 to 145months). The mean
patient age was 46 years (range, 27 to 79 years).
Cemented implants were used in 22 of 31 cases (71%),
while cementless and hybrid xation was carried out in
8 (26%) and 1 (3%) knees, respectively. In 6 knees
(19%), autologous bone grafting was deemed necessary to augment large areas of necrotic bone. In addition, 4 knees required a stemmed tibial component
and 1 knee required a stemmed femoral component.
The functional component of the KSS improved from
37 points (range, 0 to 80 points) preoperatively to 64
points (range, 20 to 100 points) at nal follow-up. The
knee component of the KSS improved from 47 points
(range, 19 to 70 points) preoperatively to 87 points
(range, 51 to 99 points) at nal follow-up. In total, 5
knees (16%) required a revision procedure including 3
cemented (13.6%) and 2 cementless (25%) knees. Three
of these 5 failures were due to aseptic loosening after
113months, 61months, and 144months. Two of the
aseptic revisions were cemented TKAs (9.1%) while 1
was cementless (12.5%). Based on the data presented
in this study, it was not possible to assess the optimal
xation technique. However, it appears that cemented
Take-Home Messages
5 Patients undergoing total knee arthroplasty for
osteonecrosis may be younger in age than those
who have osteoarthritis, and thus long-lasting
xation is imperative.
5 The overall quality of the distal femoral and
proximal tibial bone should be assessed intraoperatively to aid in the selection of cemented versus cementless xation.
5 Corticosteroid-associated knee osteonecrosis is
typically found in younger aged patients, is more
diffuse in nature compared to spontaneous
lesions, and may decrease bone density. All of
these factors are important to consider when
selecting a xation method.
5 Earlier studies have advocated the use of
cemented xation for osteonecrosis patients
undergoing TKA. However, improved biologic
xation may be achieved with newer generation
cementless implants compared to older designs.
5 Selective use of stemmed implants or bone grafts
should be used for patients in whom large areas
of necrosis may compromise xation.
and cementless techniques led to adequate outcomes.
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(2009) Characterization and pathological characteristics of
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Post-Traumatic Arthritis
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ColinT.Penrose andMichaelP.Bolognesi
Contents
6.1 Introduction – 58
6.2 Case Examples – 58
6.2.1 Case 1: Femoral Nail – 58
6.2.2
Case 2: Tibial Plateau Plate – 58
6.3 Preoperative Evaluation – 59
6.4 Intraoperative Considerations – 63
6.5 Outcomes – 64
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6
6.6 Conclusion – 64
References – 65
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_6
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C. T. Penrose and M. P. Bolognesi
6.1 Introduction
or crutches inside and required a wheelchair for longer
distances. The knee range of motion was 15–90° with
An injury causing any combination of fractures of the
tibia, femur, or patella, as well as periarticular soft tissue
injuries involving tendons, muscles, cartilage, and ligaments can eventually lead to a painful and debilitating
condition known as post-traumatic arthritis (PTA).
Total knee arthroplasty (TKA) is the treatment of
choice and should be considered when all conservative
measures have failed and after an appropriate evaluation for other etiologies.
Multiple factors can make the TKA more challenging
than a routine primary TKA including the following:
6
5 Deformity.
5 Hardware present.
5 Bone defects.
5 Scars from prior incisions or lacerations.
5 Ligamentous stability.
no extensor lag. Ligamentous examination demonstrated no signicant coronal or sagittal instability. She
was initially managed with knee joint corticosteroid
injections which provided short-term relief. After thorough discussion of risks and benets and involvement
of the pulmonary and endocrine teams for optimization of her comorbidities, the decision was made to
proceed with left total knee arthroplasty. Her prior
well-healed midline incision was extended proximally
and distally, and computer navigation was used to optimize the cutting block location without the need for an
intramedullary guide. Because of her exion contracture, an additional 2mm of distal femur was resected,
which allowed full extension to be achieved without
having to remove the femoral nail. A range of motion
from 0° to 110° was achieved intraoperatively with
appropriate medial and lateral soft tissue tension using
For these reasons, it is especially important to have a
surgical plan that may include techniques like the following:
5 Hardware removal (possibly staged).
a 13mm ultracongruent polyethylene liner (.
At early follow-up, she did well, but unfortunately she
died from complications related to her pulmonary condition prior to long-term follow-up.
Fig.6.2).
5 Technological adjuncts.
5 Increased constraint.
5 The use of cones, sleeves, or augments.
6.2.2 Case 2: Tibial Plateau Plate
5 Extensile approaches for challenging exposure.
5 Osteotomies.
A 63-year-old female, with a history of left bicondylar
tibial plateau fracture, treated initially with a knee-
The outcomes after TKA in PTA patients when compared to patients with osteoarthritis involve higher complication rates including infection, deep vein thrombosis,
and revision, as well as increased cost and lower patient
function.
spanning external xator and fasciotomies for
compartment syndrome followed by ORIF with dual
plating, presented with left knee pain (. Fig.6.3). Her
knee range of motion was 5–115° with no extensor lag.
Ligamentous examination demonstrated no signicant
ligamentous laxity. Neurovascular examination was
> However, TKA is still a very benecial operation in
this patient population when patients are appropri-
ately indicated for surgery and the operation is per-
formed using good surgical technique.
without abnormalities. Fasciotomy incisions were well
healed medially and laterally and there was a lateral
tibial plateau incision. Inammatory markers including
ESR and CRP were not elevated. After discussion of
the risks and benets and alternative options, the
patient requested to proceed with total knee
arthroplasty. Prior anterolateral incision was used and
6.2 Case Examples
then extended proximally in a more medial direction to
allow for a medial parapatellar approach.
6.2.1 Case 1: Femoral Nail
Intraoperatively, she was noted to have advanced
tricompartmental arthritic changes with a slight lateral
A 61-year-old female presented with bilateral (left
worse than right) knee pain with a history of left distal
femur fracture after falling down on icy steps which was
treated with a retrograde femoral nail (. Fig.6.1). In
addition to the retrograde femoral nail, her medical history included pulmonary brosis and diabetes and her
prior surgical history included a left ankle fracture
ORIF, lumbar spine fusion, and a hysterectomy. She
was unable to go up- or downstairs and used a walker
tibial plateau step-off. No gross evidence of infection
was present and frozen sections demonstrated no acute
inammation on pathology analysis. Limited hardware
removal of the proximal subchondral screws and the
proximal portion of the plate using a metal cutting burr
and ultrasound gel facilitated the removal of metal
shavings. Computer navigation was utilized for accuracy
of cuts and component positioning. Knee range of
motion and stability were both found to be excellent
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a
b
c
. Fig. 6.1 a–c Anteroposterior (AP), lateral, and long-standing radiographs of a 61-year-old female with PTA after prior left distal femur
fracture treated with retrograde IMN
with primary components and nal tibial, femoral, and
patellar components were cemented in place
(. Fig.6.4). At 14-year follow-up, the patient is doing
very well with no left knee pain and an excellent range
of motion from 0° to 120°. She does have some
contralateral knee pain and is considering operative
intervention on that side.
6.3 Preoperative Evaluation
Evaluation for post-traumatic painful knees should
begin with a thorough patient history with attention to
the prior trauma, subsequent treatments, and the time
course of symptoms. TKA patients undergoing conversion from a prior surgery are more likely to be younger.
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c
. Fig. 6.2 a–c Postoperative radiographs (AP, lateral, and Merchant view) after TKA with hardware retention
Several studies have shown a different comorbidity prole than other TKA patients including higher rates of
substance abuse and liver disease, but perhaps a healthier condition overall (Brophy et al. 2014; Brockman
etal. 2020; Bala etal. 2015; Dexel et al. 2016; Kester
et al. 2016). A physical examination should be performed with attention to ligamentous stability, range of
motion, neurovascular function, and skin integrity.
An intra-articular correction can generally be performed with arthroplasty until the point where it leads to
ligamentous laxity, compromises ligamentous attachments, or causes excessive bone loss (Sculco etal. 2019).
General guidelines have suggested that extra-articular
deformity less than 20° on the femur, 30° on the tibia, or
20° in the sagittal plane can be corrected with intraarticular techniques (Sculco etal. 2019). Staged osteotomy followed by knee arthroplasty is recommended for
> Radiographic evaluation should include the joint
above and below, ideally with a long-standing view to
assess alignment and deformity as well as orthogonal
views. It is critical to distinguish whether deformity
present is intra- or extra-articular or both (Benazzo
etal. 2016).
severe deformity cases and those with a signicant leg
length discrepancy that must be addressed. Peroneal
nerve injury is one potential complication when
performing acute lengthening, exion contracture
correction, and/or addressing valgus deformity and
especially when the magnitude of deformity is large. This
can be mitigated through gradual correction such as with
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a
c
d
b
. Fig. 6.3 a–d AP, lateral, Merchant, and long-standing radiographs of a 63-year-old female, with PTA after left bicondylar tibial plateau
fracture initially treated with a knee-spanning external xator, followed by ORIF
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