Results of Cementless Total Ir aee Arthroplasty in an Older R h e u m a t o i d Arthritis P o p u l a t i o n
R o b e r t A. A r m s t r o n g , D O , a n d L e o A. W h i t e s i d e , M D
Abstract: Fifty-five total knee arthroplasties (TKAs) in thirty-nine adult (mean age, 62 years) patients with rheumatoid arthritis were studied prospectively for a period of l-7years. All of the procedures were performed using cementless fixation of the tibial and femoral components. The Knee Society clinical rating system mean knee scores increased 56 points after operation (mean, 88 points), and the mean functional scores increased 28 points (mean, 64 points). Two revisions (4%) have been required, one for secondary late infection and one for failure of a cementless metal-backed patellar component. Good bone stock was retained in both, allowing for uneventful cementless revision. Forty-two arthroplasties (76%) were completely pain-free, twelve (22%) had mild, occasional discomfort with weight-bearing, and one (2%) had moderate pain at last examination. In this older rheumatoid population, cementless TKA offers good or excellent early clinical results and excellent preservation of bone stock should revision become necessary. Key words: cementless knee arthroplasty, rheumatoid arthritis
M a n y reports h a v e described the results of cementless total knee arthroplasty (TKA), but few have focused on the results in a population with rheumatoid arthritis (1, 8, 11). Some reports suggest that TKA results are poorer in a predominantly rheumatoid arthritis population, while others report no significant differences in success rates between rheumatoid and osteoarthritic patients (1, 4, 7, 9). Lucencies, bead shedding, and ~:omponent subsidence have been noted in cementless fixation of TKA'components, raising concern about adequacy of fixation and arthroplasty durability (8, 11). We are reporting the results of TKA in an adult
population with rheumatoid arthritis using cementless tibial and femoral components.
Materials and Methods Between J u n e 1983 and February 1989, 47 adult patients with rheumatoid arthritis had 67 TKAs performed using cementless fixation of the femoral and tibial components. All of the procedures w e r e performed at DePaul Health Center, St. Louis, Missouri. At the time of this study, at least 1 year after the i n d e x procedure, three patients had died and five could not be traced. This left 39 patients with 55 cementless TKAs to be included in this study. Patients were examined at 2 weeks, 1 m o n t h , 3
From the DePaul Biomechanical Research Laboratory, 3165 McKelvey Road, Suite 240, St. Louis, Missouri.
Reprint requests: Leo A. Whiteside, MD, DePaul Biomechanical Research Laboratory, 3165/McKelveyRoad, Suite 240, St. Louis, MO 63044.
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months, 6 months, and I year after operation, then yearly. Roentgenograms were obtained at 1 month and 6 months, and then at yearly examinations. Evaluation forms regarding pain, fl.nction, stability, range of motion, and roentgenographic findings were completed at each visit. The group with a full clinical and roentgenographic follow-up study lasting at least 2 years consisted of I0 men and 29 women (55 TKAs). The average clinical follow-up period was 44 months. The average age at the time of surgery was 62 years (range, 32-80 years). The average preoperative knee score was 32 points, and the average preoperative functional score was 36 points. In all patients, cementless fixation of the femoral and tibial components was used. Prior to March 1985, Ortholoc I components were used; after this date Ortholoc II components were used. The only major difference between these two prostheses is the addition of four peripheral screws to the Ortholoc II tibial component, allowing cortical purchase at all four corners of the tibial tray. Patients were given routine preoperative prophylactic antibiotics, consisting of Ancef 1 g IVPB intravenously every 8 hours for 2 days. This was followed by oral cephalosporin until discharge. Methods for .prophylaxis against deep vein thrombosis varied during the course of this study. All procedures were performed in vertical laminar-flow rooms, and the surgeons utilized body-exhaust systems. A standard midline incision was made, followed by a medial parapatellar capsular incision. Intramedullary alignment guides were used for preparation of both the tibial and femoral surfaces. All knees had posterior cruciate ligament sparing, rotationally unconstrained articular surfaces. After making the femoral and tibial cuts, the trial components were placed, and anterior, posterior, valgus, varus, and rotational stability tests were done in flexion and extension. Appropriate medial or lateral releases were performed. The patients were allowed to bear weight as tolerated the first day after surgery. All patients were interviewed and examined by one of the authors at the last postoperative exEmination. All complications are recorded. Knee and flmctional scores were assessed according to the Knee Society clinical rating system (6). Standard anteroposterior and medolateral roentgenograms were made. No effort was made to position exactly with fluoroscopy, and roentgenographic evaluation was restricted to searching for evidence of migration, bone erosion, widening .radiolucent lines, and loose bcads.
Results Two patients had late supracondylar femoral fractures. One 59-year-old man had a posteriorly angulated impacted supracondylar femoral fracture 60 months after the index procedure and was treated with closed reduction and casting. Twelve months after the fracture, he maintained an excellent knee score of 95 points and a functional score of 50 points. A 78-year-old woman fell, sustaining a closed, cornminuted supracondylar femoral fracture 24 months after tile index procedure (Fig. 1). She was treated by open reduction, internal fixation, and bone grafting (Fig. 2). This procedure was so recent as to preclude accurate reporting of her ultimate results. She was seen just 2 weeks before this injury, showing a knee score of 100 and a functional score of 55 at that time. Neither of the two fracture cases had anterior cortical notching of the femur. Two patients had patellar tendon disruptions. One complete disruption occurred during the first week after surgery. The tendon was repaired, but the restraining wire placed at surgery pulled through the
Fig. I. Anteroposterior view of closed, comminuted supracondylar femoral fracture 24 months after TKA.
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from the superolateral border of the patella, allowing a local spread of the recurrent infection of the prepatellar bursa. Despite the infection, excellent bone stock had been retained, allowing easy revision surgery following implantation of antibiotic-impregnated methylmethacrylate beads and parenteral antibiotics for 6 weeks (Fig. 4A,B). Revision has been performed so recently as to preclude accurate reporting of her ultimate result (Fig. 5A,B). The second revision was performed in an active 42-year-old man for failure of a cementless metalbacked patellar component 36 months following surgery. Good bone stock remained, allowing uneventful revision with a cemented polyethylene patellar component and cementless femoral and tibial components. He has regained an excellent result, scoring 95 points on the knee score and 60 points on the functional score at least examination. In both revision cases, gross and histological evidence of extensive bone ingrowth was found in the femoral and tibial components. A third revision surgery has been suggested in the
Fig. 2. Lateral view of open reduction, internal fixation, and bone grafting. proximal tibia, resulting in patella alta (Fig. 3). That patient has maintained a poor result, with a knee score of 21 points. He is now using an electric wheelchair due to multianicular involvement. The other extensor complication was a partial avulsion of the quadriceps tendon from the superolateral border of the patella, found at the time of implant removal in the only infected anhroplasty in this series. Two revision procedures have been performed. One revision was done in a 76-year-old w o m a n for a late infection that occurred 79 months after the index procedure. This patient had a chronic, recurrent, infectious prepatellar bursitis, treated by her family physician with interminent antibiotics. She had not returned to our office for follow-up evaluation for several years prior to the onset of severe knee pain. When seen in the office she appeared to have another episode of infectious bursitis, ttowever, following aspiration of the bursa to obtain fluid for culture, flexion and extension of the knee caused the cyst-like structure to refill. At surgery she was found to have a partial avulsion of the quadriceps tendon
Fig. 3. Patellar tendon disruption in which.the restraining wire placed at surgery pulled through the.proximal tibia, resulting in petalla alia.
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The Journal of Arthroplasty Vol. 6 No. 4 December 1991
Fig. 4. (A) Anteroposterior and (B) mediolateral views of implant removal and implantation of antibiotic-impregnated methylmethacrylate beads, for treatment of infected prepatellar bursa.
case of 63-year-old m a n at 47 m o n t h s after index surgery. He also has had failure of a cementless, metal-backed patellar c o m p o n e n t , but has refused furiher surgery. Routine investigations were not performed to det e c t t h r o m b o e m b o l i c complications, and n o n e was d o c u m e n t e d on hospital or office records. The m e a n preoperative knee score was 32 points, and the m e a n postoperative knee score at last ex9amination was 88. The m e a n preoperative functional score was 36, and the m e a n postoperative functional score at last follow-up evaluation was 64. Only one patient, the patient frith complete quadriceps tendon disruption, scored fewer points after operation than before operation. Postoperative roentgenograms were obtained at 1 month, 6 months, and 1 year after operation and were repeated at yearly examinations. All roentgenograms w e r e assessed for lucent lines, loose beads, cysts developing around components, and component migration or s.ubsidence. Lucencies of 1 m m or
less in femoral zone 1 were found in 11 knees; lucencies in femoral zone 4 were found in 2 knees (Fig. 6). There were 2 - m m lucencies in two arthroplasties in femoral zone 1 and in two knees in femoral zone 4. Tibial lucencies of 1 m m or less were noted in zone 1 in three knees, in zone 2 in two patients, in zone 3 in one patient, and in zone 4 in one patient. No arthroplasty had evidence of tibial c o m p o n e n t subsidence as defined by a change of 3 ~ in the angle formed by the base of the c o m p o n e n t and the tibial shaft. Cysts were not found around any of the pegs or screws of either c o m p o n e n t . One knee was noted to have a single loose bead on postoperative roentgenograms. It seemed to have c o m e from the femoral component, but appeared to be extraarticular. At last follow-up evaluation, 42 (81%) of the arthroplasties were pain-free, 12 (16%) had mild, occasional discomfort u p o n weight bearing, and 2 (3%) had moderate pain at rest. The one patient with pain at rest was the m a n w h o had sustained complete quadriceps tendon disruption.
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Fig. 5. (A) Anteroposterior and (B) mediolateral views of revision following treatment for infection.
Discussion
|
3
Fig. 6. Femoral and tibial components, indicating zones in which luccncics wcrc observed 2 years after operation.
Evaluation was done with the Knee Society clinical rating system to simplify the evaluation of the knee and include a separate rating of the whole patient. Knee scores were not adversely affected if multiarticular involvement caused poor functional scores. This group of rheumatoid arthritic adult patients included m a n y patients with multiarticular involvement whose knee scores may not have been accurately reflected if other scoring systems were used. After a minimum Of 2 postoperative years 81% of tile arthroplasties were pain-free. This compares favorably to other cementless arthroplasty series, such as that of Laskin, who reported 74 of 96 pain-free knees (77%) at 2 postoperative years. His series inchided 55 patients with rheumatoid arthritis (8). AIbrektsson and Herberts reported 30% with slight or moderate pain in their follow-up study of results with the ICLH cementless prosthesis in 108 arthroplasties in 82 people, 55 of w h o m had rheumatoid
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The Journal of Arthroplasty Vol. 6 No. 4 December 1991
arthritis (1). They reported no significant difference in relief of pain between their rheumatoid arthritis and osteoarthritis patients. While some series report relatively high percentages of pain relief after cemented TKA, there is no concensus in the literature regarding superiority of cemented over cementless fixation in their ability to achieve pain relief. Stuart and Rand reported 5 of 44 (11%) young rheumatoid arthritic patients having pain after cemented knee arthroplasties (4). Sarokhan's series had 20 of 21 knees with complete relief of discomfort after operation (12). ttowever, Rosenberg (Orthop, 1989) reported 73% pain-free knees after cemented arthroplasty in a mixed series (10). Ewald reported 92% of knees had no pain or mild pain 2 years after cemented TKA in a mixed population (2). Tile finding of 97% of knees with no pain or mild pain in the present series compares favorably to these recent reports of cemented TKA. Hungerford et ai. reported good results in young rheumatoid arthritis patients with cementless TKA and concluded that the younger patient with rheumatoid arthritis and good bone sto~k is an excellent choice for a cementless arthroplasty (5). The present report suggests that older patients with rheumatoid arthritis are also good candidates for cementless TKA. Patellar failures have resulted in the need for revision in two arthroplasties (4%) in this series. No aseptic loosening of tibial or femoral components has occurred in this series. All three knees with failed components in this series had good bone stock, and revision arthroplasty could be performed with cemeritless components. Although cementless TKA is a technically demanding procedure, it is reliable in the older rheumatoid patient. It is also conservative of bone, and in this population with frequent late complications, preservation of bone is a major factor facilitating revision. Because of the good quality of clinical results in this population of patients, we con-
clude that the use of cementless TKA is justified in older rheumatoid patients.
References 1. Albrektsson BEJ, lterberts P: ICLtt knee arthroplasty. J Arthroplasty 3:145, 1988 2. Ewald FC, Jacobs MA, Miegel RE et al: Kinematic total knee replacement. J Bone Joint Surg 66A: 1032, 1984 3. Ewald FC: The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop 245:9, 1989 4. Grimer RJ, Karpinsky MRU, Edward AN: The longterm results of Stanmore total knee replacements.'J Bone Joint Surg 67B:548, 1984 5. ttungerford DS, Krackow KA, Kenna RV: Cementless total knee replacement in patients 50 years old and older. Orthop Clin North Am 20:131, 1989 6. lnsall JN, Dorr LD, Scott RD, Scott NW: Rationale of the Knee Society clinical rating system. Clin Orthop 248:13, 1989 7. Knuesson V, Tjornstrand B, Lindgren L: Survival of knee arthroplasties for rheumatoid arthritis. Acta Orthop Scand 56:422, 1985 8. Laskin R: Tricon-M uncemented total knee arthroptasty. J Arthroplasty 3:27, 1988 9. Levallen DG, Bryan RS, Peterson LFA: Poly total knee arthrnptasty. J Bone Joint Surg 66A:1211, 1984 10. Rosenberg AG, Barden R, Galante JO: A comparison of cemented and cementless fixation with the MillerGalante total knee arthroplasty. Orthop Clin North Am 20:97, 1989 1 !. Rosenquist R, Bylander B, Knutson K et al: Loosening of the porous coating of biocompartmental prosthesis in patients with rheumatoid arthritis. J Bone Joint Surg 68A:538, 1988 12. Sarokhan AJ, Scott RD, Thomas WHet el: Total knee arthroplasty in juvenile rheumatoid arthritis. J'Bone Joint Surg 65A:1071, 1983
R o b e r t A. A r m s t r o n g , D O , a n d L e o A. W h i t e s i d e , M D
Abstract: Fifty-five total knee arthroplasties (TKAs) in thirty-nine adult (mean age, 62 years) patients with rheumatoid arthritis were studied prospectively for a period of l-7years. All of the procedures were performed using cementless fixation of the tibial and femoral components. The Knee Society clinical rating system mean knee scores increased 56 points after operation (mean, 88 points), and the mean functional scores increased 28 points (mean, 64 points). Two revisions (4%) have been required, one for secondary late infection and one for failure of a cementless metal-backed patellar component. Good bone stock was retained in both, allowing for uneventful cementless revision. Forty-two arthroplasties (76%) were completely pain-free, twelve (22%) had mild, occasional discomfort with weight-bearing, and one (2%) had moderate pain at last examination. In this older rheumatoid population, cementless TKA offers good or excellent early clinical results and excellent preservation of bone stock should revision become necessary. Key words: cementless knee arthroplasty, rheumatoid arthritis
M a n y reports h a v e described the results of cementless total knee arthroplasty (TKA), but few have focused on the results in a population with rheumatoid arthritis (1, 8, 11). Some reports suggest that TKA results are poorer in a predominantly rheumatoid arthritis population, while others report no significant differences in success rates between rheumatoid and osteoarthritic patients (1, 4, 7, 9). Lucencies, bead shedding, and ~:omponent subsidence have been noted in cementless fixation of TKA'components, raising concern about adequacy of fixation and arthroplasty durability (8, 11). We are reporting the results of TKA in an adult
population with rheumatoid arthritis using cementless tibial and femoral components.
Materials and Methods Between J u n e 1983 and February 1989, 47 adult patients with rheumatoid arthritis had 67 TKAs performed using cementless fixation of the femoral and tibial components. All of the procedures w e r e performed at DePaul Health Center, St. Louis, Missouri. At the time of this study, at least 1 year after the i n d e x procedure, three patients had died and five could not be traced. This left 39 patients with 55 cementless TKAs to be included in this study. Patients were examined at 2 weeks, 1 m o n t h , 3
From the DePaul Biomechanical Research Laboratory, 3165 McKelvey Road, Suite 240, St. Louis, Missouri.
Reprint requests: Leo A. Whiteside, MD, DePaul Biomechanical Research Laboratory, 3165/McKelveyRoad, Suite 240, St. Louis, MO 63044.
357
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The Journal of Arthroplasty Vol. 6 No. 4 December 1991
months, 6 months, and I year after operation, then yearly. Roentgenograms were obtained at 1 month and 6 months, and then at yearly examinations. Evaluation forms regarding pain, fl.nction, stability, range of motion, and roentgenographic findings were completed at each visit. The group with a full clinical and roentgenographic follow-up study lasting at least 2 years consisted of I0 men and 29 women (55 TKAs). The average clinical follow-up period was 44 months. The average age at the time of surgery was 62 years (range, 32-80 years). The average preoperative knee score was 32 points, and the average preoperative functional score was 36 points. In all patients, cementless fixation of the femoral and tibial components was used. Prior to March 1985, Ortholoc I components were used; after this date Ortholoc II components were used. The only major difference between these two prostheses is the addition of four peripheral screws to the Ortholoc II tibial component, allowing cortical purchase at all four corners of the tibial tray. Patients were given routine preoperative prophylactic antibiotics, consisting of Ancef 1 g IVPB intravenously every 8 hours for 2 days. This was followed by oral cephalosporin until discharge. Methods for .prophylaxis against deep vein thrombosis varied during the course of this study. All procedures were performed in vertical laminar-flow rooms, and the surgeons utilized body-exhaust systems. A standard midline incision was made, followed by a medial parapatellar capsular incision. Intramedullary alignment guides were used for preparation of both the tibial and femoral surfaces. All knees had posterior cruciate ligament sparing, rotationally unconstrained articular surfaces. After making the femoral and tibial cuts, the trial components were placed, and anterior, posterior, valgus, varus, and rotational stability tests were done in flexion and extension. Appropriate medial or lateral releases were performed. The patients were allowed to bear weight as tolerated the first day after surgery. All patients were interviewed and examined by one of the authors at the last postoperative exEmination. All complications are recorded. Knee and flmctional scores were assessed according to the Knee Society clinical rating system (6). Standard anteroposterior and medolateral roentgenograms were made. No effort was made to position exactly with fluoroscopy, and roentgenographic evaluation was restricted to searching for evidence of migration, bone erosion, widening .radiolucent lines, and loose bcads.
Results Two patients had late supracondylar femoral fractures. One 59-year-old man had a posteriorly angulated impacted supracondylar femoral fracture 60 months after the index procedure and was treated with closed reduction and casting. Twelve months after the fracture, he maintained an excellent knee score of 95 points and a functional score of 50 points. A 78-year-old woman fell, sustaining a closed, cornminuted supracondylar femoral fracture 24 months after tile index procedure (Fig. 1). She was treated by open reduction, internal fixation, and bone grafting (Fig. 2). This procedure was so recent as to preclude accurate reporting of her ultimate results. She was seen just 2 weeks before this injury, showing a knee score of 100 and a functional score of 55 at that time. Neither of the two fracture cases had anterior cortical notching of the femur. Two patients had patellar tendon disruptions. One complete disruption occurred during the first week after surgery. The tendon was repaired, but the restraining wire placed at surgery pulled through the
Fig. I. Anteroposterior view of closed, comminuted supracondylar femoral fracture 24 months after TKA.
Cementless TKA in an Older Rheumatoid Arthritis Population
9 Armstrong and Whiteside
359
from the superolateral border of the patella, allowing a local spread of the recurrent infection of the prepatellar bursa. Despite the infection, excellent bone stock had been retained, allowing easy revision surgery following implantation of antibiotic-impregnated methylmethacrylate beads and parenteral antibiotics for 6 weeks (Fig. 4A,B). Revision has been performed so recently as to preclude accurate reporting of her ultimate result (Fig. 5A,B). The second revision was performed in an active 42-year-old man for failure of a cementless metalbacked patellar component 36 months following surgery. Good bone stock remained, allowing uneventful revision with a cemented polyethylene patellar component and cementless femoral and tibial components. He has regained an excellent result, scoring 95 points on the knee score and 60 points on the functional score at least examination. In both revision cases, gross and histological evidence of extensive bone ingrowth was found in the femoral and tibial components. A third revision surgery has been suggested in the
Fig. 2. Lateral view of open reduction, internal fixation, and bone grafting. proximal tibia, resulting in patella alta (Fig. 3). That patient has maintained a poor result, with a knee score of 21 points. He is now using an electric wheelchair due to multianicular involvement. The other extensor complication was a partial avulsion of the quadriceps tendon from the superolateral border of the patella, found at the time of implant removal in the only infected anhroplasty in this series. Two revision procedures have been performed. One revision was done in a 76-year-old w o m a n for a late infection that occurred 79 months after the index procedure. This patient had a chronic, recurrent, infectious prepatellar bursitis, treated by her family physician with interminent antibiotics. She had not returned to our office for follow-up evaluation for several years prior to the onset of severe knee pain. When seen in the office she appeared to have another episode of infectious bursitis, ttowever, following aspiration of the bursa to obtain fluid for culture, flexion and extension of the knee caused the cyst-like structure to refill. At surgery she was found to have a partial avulsion of the quadriceps tendon
Fig. 3. Patellar tendon disruption in which.the restraining wire placed at surgery pulled through the.proximal tibia, resulting in petalla alia.
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The Journal of Arthroplasty Vol. 6 No. 4 December 1991
Fig. 4. (A) Anteroposterior and (B) mediolateral views of implant removal and implantation of antibiotic-impregnated methylmethacrylate beads, for treatment of infected prepatellar bursa.
case of 63-year-old m a n at 47 m o n t h s after index surgery. He also has had failure of a cementless, metal-backed patellar c o m p o n e n t , but has refused furiher surgery. Routine investigations were not performed to det e c t t h r o m b o e m b o l i c complications, and n o n e was d o c u m e n t e d on hospital or office records. The m e a n preoperative knee score was 32 points, and the m e a n postoperative knee score at last ex9amination was 88. The m e a n preoperative functional score was 36, and the m e a n postoperative functional score at last follow-up evaluation was 64. Only one patient, the patient frith complete quadriceps tendon disruption, scored fewer points after operation than before operation. Postoperative roentgenograms were obtained at 1 month, 6 months, and 1 year after operation and were repeated at yearly examinations. All roentgenograms w e r e assessed for lucent lines, loose beads, cysts developing around components, and component migration or s.ubsidence. Lucencies of 1 m m or
less in femoral zone 1 were found in 11 knees; lucencies in femoral zone 4 were found in 2 knees (Fig. 6). There were 2 - m m lucencies in two arthroplasties in femoral zone 1 and in two knees in femoral zone 4. Tibial lucencies of 1 m m or less were noted in zone 1 in three knees, in zone 2 in two patients, in zone 3 in one patient, and in zone 4 in one patient. No arthroplasty had evidence of tibial c o m p o n e n t subsidence as defined by a change of 3 ~ in the angle formed by the base of the c o m p o n e n t and the tibial shaft. Cysts were not found around any of the pegs or screws of either c o m p o n e n t . One knee was noted to have a single loose bead on postoperative roentgenograms. It seemed to have c o m e from the femoral component, but appeared to be extraarticular. At last follow-up evaluation, 42 (81%) of the arthroplasties were pain-free, 12 (16%) had mild, occasional discomfort u p o n weight bearing, and 2 (3%) had moderate pain at rest. The one patient with pain at rest was the m a n w h o had sustained complete quadriceps tendon disruption.
Cementless TKA in an Older Rheumatoid Arthritis Population
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Fig. 5. (A) Anteroposterior and (B) mediolateral views of revision following treatment for infection.
Discussion
|
3
Fig. 6. Femoral and tibial components, indicating zones in which luccncics wcrc observed 2 years after operation.
Evaluation was done with the Knee Society clinical rating system to simplify the evaluation of the knee and include a separate rating of the whole patient. Knee scores were not adversely affected if multiarticular involvement caused poor functional scores. This group of rheumatoid arthritic adult patients included m a n y patients with multiarticular involvement whose knee scores may not have been accurately reflected if other scoring systems were used. After a minimum Of 2 postoperative years 81% of tile arthroplasties were pain-free. This compares favorably to other cementless arthroplasty series, such as that of Laskin, who reported 74 of 96 pain-free knees (77%) at 2 postoperative years. His series inchided 55 patients with rheumatoid arthritis (8). AIbrektsson and Herberts reported 30% with slight or moderate pain in their follow-up study of results with the ICLH cementless prosthesis in 108 arthroplasties in 82 people, 55 of w h o m had rheumatoid
362
The Journal of Arthroplasty Vol. 6 No. 4 December 1991
arthritis (1). They reported no significant difference in relief of pain between their rheumatoid arthritis and osteoarthritis patients. While some series report relatively high percentages of pain relief after cemented TKA, there is no concensus in the literature regarding superiority of cemented over cementless fixation in their ability to achieve pain relief. Stuart and Rand reported 5 of 44 (11%) young rheumatoid arthritic patients having pain after cemented knee arthroplasties (4). Sarokhan's series had 20 of 21 knees with complete relief of discomfort after operation (12). ttowever, Rosenberg (Orthop, 1989) reported 73% pain-free knees after cemented arthroplasty in a mixed series (10). Ewald reported 92% of knees had no pain or mild pain 2 years after cemented TKA in a mixed population (2). Tile finding of 97% of knees with no pain or mild pain in the present series compares favorably to these recent reports of cemented TKA. Hungerford et ai. reported good results in young rheumatoid arthritis patients with cementless TKA and concluded that the younger patient with rheumatoid arthritis and good bone sto~k is an excellent choice for a cementless arthroplasty (5). The present report suggests that older patients with rheumatoid arthritis are also good candidates for cementless TKA. Patellar failures have resulted in the need for revision in two arthroplasties (4%) in this series. No aseptic loosening of tibial or femoral components has occurred in this series. All three knees with failed components in this series had good bone stock, and revision arthroplasty could be performed with cemeritless components. Although cementless TKA is a technically demanding procedure, it is reliable in the older rheumatoid patient. It is also conservative of bone, and in this population with frequent late complications, preservation of bone is a major factor facilitating revision. Because of the good quality of clinical results in this population of patients, we con-
clude that the use of cementless TKA is justified in older rheumatoid patients.
References 1. Albrektsson BEJ, lterberts P: ICLtt knee arthroplasty. J Arthroplasty 3:145, 1988 2. Ewald FC, Jacobs MA, Miegel RE et al: Kinematic total knee replacement. J Bone Joint Surg 66A: 1032, 1984 3. Ewald FC: The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop 245:9, 1989 4. Grimer RJ, Karpinsky MRU, Edward AN: The longterm results of Stanmore total knee replacements.'J Bone Joint Surg 67B:548, 1984 5. ttungerford DS, Krackow KA, Kenna RV: Cementless total knee replacement in patients 50 years old and older. Orthop Clin North Am 20:131, 1989 6. lnsall JN, Dorr LD, Scott RD, Scott NW: Rationale of the Knee Society clinical rating system. Clin Orthop 248:13, 1989 7. Knuesson V, Tjornstrand B, Lindgren L: Survival of knee arthroplasties for rheumatoid arthritis. Acta Orthop Scand 56:422, 1985 8. Laskin R: Tricon-M uncemented total knee arthroptasty. J Arthroplasty 3:27, 1988 9. Levallen DG, Bryan RS, Peterson LFA: Poly total knee arthrnptasty. J Bone Joint Surg 66A:1211, 1984 10. Rosenberg AG, Barden R, Galante JO: A comparison of cemented and cementless fixation with the MillerGalante total knee arthroplasty. Orthop Clin North Am 20:97, 1989 1 !. Rosenquist R, Bylander B, Knutson K et al: Loosening of the porous coating of biocompartmental prosthesis in patients with rheumatoid arthritis. J Bone Joint Surg 68A:538, 1988 12. Sarokhan AJ, Scott RD, Thomas WHet el: Total knee arthroplasty in juvenile rheumatoid arthritis. J'Bone Joint Surg 65A:1071, 1983
