During the followup period, there were five revisions of the femoral or tibial component (2.5%), two of which were not related to an infection (two of 201 [1.0%]). Both aseptic revisions resulted from medial tibial collapse secondary to loosening, and both knee systems had a well-fixed femoral component at revision. The aseptic revisions included one in a 70-year-old man and one in a 65-year-old woman; both were treated primarily for osteoarthritis. The two tibial components were in 90° coronal alignment; the overall anatomic alignment for one knee was in 5° valgus, whereas the other was 0°. Both patients had a pain score of 50.
There were three knees (two tibial components, discussed previously, and one femur) that were considered radiographically loose. The loose femoral component, in a 62-year-old man treated for osteoarthritis, did not require revision; the overall alignment was 4° valgus and 87° coronal tibial alignment. The patient had a pain score of 50. Although there were radiographic signs of loosening, there was no change in alignment or migration of the prostheses.
At final followup, we found radiolucencies adjacent to the femoral component in 15 of 194 knees (7.7%). Seven radiolucencies were found in Zone 1, three in Zone 2, five in Zone 3, one in Zone 4, two in Zone 5, and zero in Zone 6. One hundred twenty-five of 176 knees had no radiolucency at 1 year followup (71.0%), 117 of 136 had no radiolucency at 3 years (86.0%), 78 of 87 had no radiolucency at 5 years (89.7%), 54 of 59 had no radiolucency at 10 years (91.5%), and 11 of 12 had no radiolucency at 15 years (91.7%). Radiolucencies greater than 2 mm at earlier followup, typically found around the anterior or posterior femoral flanges, did not increase in size or compromise the implant; all such lucencies did not progress into adjacent zones.
On primary radiographic evaluation, we found nine osteolytic lesions in eight of 201 knees (4.0%), but only one of these nine lesions (in 0.5% of 201 knees) was determined to possibly be wear osteolysis after secondary evaluation; the other eight were small, medial, and nonprogressive. Two lesions were found surrounding a femoral component, whereas the other seven were found in the tibia. One femoral lesion was located adjacent to the anterior flange with the other adjacent to the posterior flange; these were determined to be related to poor coaptation of the femoral flanges, and not polyethylene wear, on secondary evaluation. All seven tibial lesions were found in the medial tibial plateau. Six of these appeared within 5 mm of the edge of the plateau; they first appeared at 6 months followup and were nonprogressive; thus, they were deemed nonosteolytic at secondary evaluation. The area of concern for osteolysis in the one knee with possible osteolysis after secondary evaluation was noted at 3 years followup; the area became more prominent, but it did not expand during the 15-year followup period. One knee had two lesions that were visualized, one in the medial tibia and one in the anterior femur but both were deemed nonosteolytic. All patients with apparent osteolysis determined at primary evaluation, with the exception of those who had revision surgery, had a pain score of 50.
Three supracondylar femoral fractures occurred in the study group. These fractures, which appeared near the distal third of the right femur, were treated with Rush rods; all healed sufficiently. We performed three revision arthroplasties secondary to infection in two patients within 2 years after the index surgery; these were revised with modular Insall-Burstein constrained prostheses (Zimmer, Warsaw, IN). Seven manipulations and three lateral releases were performed. Other operations included seven manipulations, three lateral releases, and one patellar button excision.
Cementless fixation in TKA was developed to negate the problems associated with cemented TKA; however, in light of the mixed results associated with cementless TKA [11, 12, 13, 17, 19, 20, 27, 39, 40], hybrid fixation was put forth as an alternative. In initial studies [28, 30, 49, 58], this method showed success rates comparable with those of the cemented femoral Miller-Galante and PFC components; however, the studies relied on short followup and stressed further study was warranted. Campbell et al.  cited 10 revisions among 65 PFC implants and 84.6% survivorship at 8 years; these findings led them to conclude hybrid fixation should be abandoned. On seeing these results and reports [22, 24, 29, 34] suggesting increased success rates could result from patient selection, we decided to examine data concerning our center's experience with hybrid TKAs.
One limitation of this study was the reliance on standard radiographs to observe osteolysis [23, 35]. However, the same two technicians took all the radiographs and their techniques are the same. Moreover, the scarcity of revisions in this study group suggests possible unobserved osteolysis did not complicate the integrity of the implants.
Comparisons among fixation techniques in primary TKAs have been produced in studies using databases with greater than 5700 knee arthroplasties [17, 19, 39, 40]. In two of these reports [19, 40], such comparisons included the survival rates of cemented, cementless, and hybrid TKAs. Both found the survivorship of cemented components to be superior to the latter two methods, with cemented implants having success rates of 99% and 92%, respectively (Table 1). These findings give credence to cemented fixation's distinction as the gold standard against which all other fixation methods are compared. However, hybrid fixation has consistently shown more success than cementless techniques, as seen by the 97.3% 13-year success rate found in the current study. This is partly attributable to the improved surgical procedure and continued, but tempered, evolution of components.
Hybrid TKA has shown good short-term and intermediate-term results. Although cemented fixation has consistently had excellent survival rates, careful selection of patients based on component fit may increase survivorship seen in hybrid fixation. Further study, especially analysis of greater than 15-year survival, is warranted and would add considerably to the debate concerning the optimal method of fixation in primary TKA.
We thank Matthew Brunsman for statistical analysis and graphics design.
1. Arora J, Ogden AC. Osteolysis in a surface-cemented, primary, modular Freeman-Samuelson total knee replacement. J Bone Joint Surg Br
2. Bauer GC. What price progress? Failed innovations of the knee prosthesis. Acta Orthop Scand
3. Berry DJ, Wold LE, Rand JA. Extensive osteolysis around an aseptic, stable, uncemented total knee replacement. Clin Orthop Relat Res
4. Bozic KJ, Kinder J, Menegini M, Zurakowski D, Rosenberg AG, Galante JO. Implant survivorship and complication rates after total knee arthroplasty with a third-generation cemented system: 5 to 8 years followup. Clin Orthop Relat Res
5. Bulstrode CJ, Murray DW, Carr AJ, Pynsent PB, Carter SR. Designer hips: don't let your patient become a fashion victim. BMJ
6. Campbell MD, Duffy GP, Trousdale RT. Femoral component failure in hybrid total knee arthroplasty. Clin Orthop Relat Res
7. Carlsson Å, Björkman A, Besjakov J, Önsten I. Cemented tibial component fixation performs better than cementless fixation: a randomized radiostereometric study comparing porous-coated, hydroxyapatite-coated and cemented tibial components over 5 years. Acta Orthop
8. Collier JP, Mayor MB, Surprenant VA, Dauphinais LA, Surprenant HP, Jensen RE, Chae JC, Spector M, Shortkroff S, Sledge CB, et al. Advances in implant-bone interface. Instr Course Lect
9. Collier MB, Engh CA Jr, McAuley JP, Ginn SD, Engh GA. Osteolysis after total knee arthroplasty: influence of tibial baseplate surface finish and sterilization of polyethylene insert. J Bone Joint Surg Am
10. Conditt MA, Thompson MT, Usrey MM, Ismaily SK, Noble PC. Backside wear of polyethylene tibial inserts: mechanism and magnitude of material loss. J Bone Joint Surg Am
11. Cook SD, Thomas KA, Haddad RJ Jr. Histologic analysis of retrieved human porous-coated total joint components. Clin Orthop Relat Res
12. Duffy GP, Berry DJ, Rand JA. Cement versus cementless fixation in total knee arthroplasty. Clin Orthop Relat Res
13. Duffy GP, Murray BE, Trousdale RR. Hybrid total knee arthroplasty: analysis of component failures at an average of 15 years. J Arthroplasty
14. Engh GA, Dwyer KA, Hanes CK. Polyethylene wear of metal-backed tibial components in total and unicompartmental knee prostheses. J Bone Joint Surg Br
15. Engh GA, Parks NL, Ammeen DJ. Tibial osteolysis in cementless total knee arthroplasty: a review of 25 cases treated with and without tibial component revision. Clin Orthop Relat Res
16. Ezzet KA, Garcia R, Barrack RL. Effect of component fixation method on osteolysis in total knee arthroplasty. Clin Orthop Relat Res
17. Furnes O, Espehaug B, Lie SA, Furnes O, Havelin LI. Early failures among 7,174 primary total knee replacements: a follow-up study from the Norwegian Arthroplasty Register 1994-2000. Acta Orthop Scand
18. Gioe TJ, Bowman KR. A randomized comparison of all-polyethylene and metal-backed tibial components. Clin Orthop Relat Res
19. Gioe TJ, Killeen KK, Grimm K, Mehle S, Scheltema K. Why are total knee replacements revised?: analysis of early revision in a community knee implant registry. Clin Orthop Relat Res
20. Goldberg VM, Kraay M. The outcome of the cementless tibial component: a minimum 14-year clinical evaluation. Clin Orthop Relat Res
21. Goodfellow J. Editorials. Knee prostheses—ne step forward, two steps back. J Bone Joint Surg Br
22. Hsu RW, Tsai YH, Huang TJ, Chang JC. Hybrid total knee arthroplasty: a 3- to 6-year outcome analysis. J Formos Med Assoc
23. 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
24. Illgen R, Tueting J, Enright T, Schreibman K, McBeath A, Heiner J. Hybrid total knee arthroplasty: a retrospective analysis of clinical and radiographic outcomes at average 10 years follow-up. J Arthroplasty
2004;19(7 suppl 2):95-100. doi:10.1016/j.arth.2004.06.022.
25. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc
26. Kilgus DJ, Funahashi TT, Campbell PA. Massive femoral osteolysis and early disintegration of a polyethylene-bearing surface of a total knee replacement: a case report. J Bone Joint Surg Am
27. Kim YH, Oh JH, Oh SH. Osteolysis around cementless porous-coated anatomic knee prostheses. J Bone Joint Surg Br
28. Kobs JK, Lachiewicz PF. Hybrid total knee arthroplasty: two- to five-year results using the Miller-Galante prosthesis. Clin Orthop Relat Res
29. König A, Kirschner S, Walther M, Eisert M, Eulert J. Hybrid total knee arthroplasty. Arch Orthop Trauma Surg
30. Kraay MJ, Meyers SA, Goldberg VM, Figgie HE II, Conroy PA. “Hybrid” total knee arthroplasty with the Miller-Galante prosthesis: a prospective clinical and roentgenographic evaluation. Clin Orthop Relat Res
31. Lachiewicz PF, Soileau ES. The rates of osteolysis and loosening associated with a modular posterior stabilized knee replacement: results at 5-14 years. J Bone Joint Surg Am
32. Lewis P, Rorabeck CH, Bourne RB, Devane P. Posteromedial tibial polyethylene failure in total knee replacements. Clin Orthop Relat Res
33. Li MG, Nilsson KG. The effect of the preoperative bone quality on the fixation of the tibial component in total knee arthroplasty. J Arthroplasty
34. Mitsui H. Hybrid total knee arthroplasties in rheumatoid arthritis. Bull Hosp Jt Dis
35. Miura H, Matsuda S, Okazaki K, Kawano T, Kawamura H, Iwamoto Y. Validity of an oblique posterior condylar radiographic view for revision total knee arthroplasty. J Bone Joint Surg Br
36. 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
37. Peters PC Jr, Engh GA, Dwyer KA, Vinh TN. Osteolysis after total knee arthroplasty without cement. J Bone Joint Surg Am
38. Puloske 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
39. Rand JA, Ilstrup DM. Survivorship analysis of total knee arthroplasty: cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am
40. Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg Am
41. Rao AR, Engh GA, Collier MB, Lounici S. Tibial interface wear in retrieved total knee components and correlations with modular insert motion. J Bone Joint Surg Am
42. Ritter MA. Screw and cement fixation of large defects in total knee arthroplasty. J Arthroplasty
43. Ritter MA, Berend ME, Meding JB, Keating EM, Faris PM, Crites BM. Long-term follow-up of Anatomic Graduated Components posterior cruciate-retaining total knee replacement. Clin Orthop Relat Res
44. Ritter MA, Harty LD. Medial screws and cement: a possible mechanical augmentation in total knee arthroplasty. J Arthroplasty
45. Ritter MA, Herbst SA, Keating EM, Faris PM, Meding JB. Long-term survival analysis of a posterior-cruciate-retaining total condylar total knee arthroplasty. Clin Orthop Relat Res
46. Ritter MA, Keating EM, Faris PM. Screw and cement fixation of large defects in total knee arthroplasty a sequel. J Arthroplasty
47. Robinson EJ, Mulliken BD, Bourne RB, Rorabeck CH, Alvarez C. Catastrophic osteolysis in total knee replacement: a report of 17 cases. Clin Orthop Relat Res
48. Rodriguez JA, Baez N, Rasquinha V, Ranawat CS. Metal-backed and all-polyethylene tibial components in total knee replacement. Clin Orthop Relat Res
49. Rorabeck CH, Bourne RB, Lewis PL, Nott L. The Miller-Galante knee prosthesis for the treatment of osteoarthrosis: a comparison of the results of partial fixation with cement and fixation without any cement. J Bone Joint Surg Am
50. Schmalzried TP, Callaghan JJ. Current concepts review: wear in total hip and knee replacements. J Bone Joint Surg Am
51. Schrøder HM, Berthelsen A, Hassani G, Hansen EB, Solgaard S. Cementless porous-coated total knee arthroplasty: 10-year results in a consecutive series. J Arthroplasty
52. Smith S, Naima VS, Freeman MA. The natural history of tibial radiolucent lines in a proximally cemented stemmed total knee arthroplasty. J Arthroplasty
53. Tanner MG, Whiteside LA, White SE. Effect of polyethylene quality on wear in total knee arthroplasty. Clin Orthop Relat Res
54. Vigorita VJ, Minkowitz B, Dichiara JF, Higham PA. A histomorphometric and histologic analysis of the implant interface in five successful, autopsy-retrieved, noncemented porous-coated knee arthroplasties. Clin Orthop Relat Res
55. Wasielewski RC, Galante JO, Leighty RM, Natarajan RN, Rosenberg AG. Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty. Clin Orthop Relat Res
56. Wasielewski RC, Parks N, Williams SI, Surprenant H, Collier JP, Engh G. Tibia insert undersurface as a contributing source of polyethylene wear debris. Clin Orthop Relat Res
57. Whiteside LA. Effect of porous-coating configuration on tibial osteolysis after total knee arthroplasty. Clin Orthop Relat Res
58. Wright RJ, Lima J, Scott RD, Thornhill TS. Two- to four-year results of posterior cruciate-sparing condylar total knee arthroplasty with an uncemented femoral component. Clin Orthop Relat Res