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C OPYRIGHT Ó 2012 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

High-Flexion Total Knee Arthroplasty:

Survivorship and Prevalence of Osteolysis
Results After a Minimum of Ten Years of Follow-up
Young-Hoo Kim, MD, Jang-Won Park, MD, and Jun-Shik Kim, MD

Investigation performed at the Joint Replacement Center, Ewha Womans University School of Medicine, Seoul, South Korea

Background: We are aware of no information about the mid-term performance of the high-flexion total knee arthroplasty,
although early results have been reported. The purpose of this study was to evaluate the mid-term results of high-flexion
and conventional knee prostheses.
Methods: We prospectively compared the results of 100 patients with osteoarthritis who had received a NexGen Legacy
Posterior Stabilized (NexGen LPS) prosthesis in one knee and a NexGen Legacy Posterior Stabilized-Flex (NexGen LPS-
Flex) prosthesis in the other. Seventy-five patients (150 knees) were women and twenty-five (fifty knees) were men. The
mean age was sixty-five years (range, forty-eight to eighty-five years) at the time of the index procedure. The mean duration
of follow-up was 10.3 years (range, ten to 10.6 years). The patients were assessed with radiographs, with the rating
system of the Knee Society, and with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score
at three months, one year, and annually thereafter.
Results: Total knee scores, knee function scores, pain scores, WOMAC scores, knee motion, and activity scores did not
differ significantly between the two designs of the implants, on the basis of the numbers studied, either preoperatively or
at the time of final follow-up. One knee in the NexGen LPS-Flex group was revised because of recurrent infection. No knee
in either group had aseptic loosening of the components. The Kaplan-Meier survivorship at ten years postoperatively, with
revision defined as the end point, was 100% (95% confidence interval, 94 to 100) for the NexGen LPS prosthesis and 99%
(95% confidence interval, 93 to 100) for the NexGen LPS-Flex prosthesis.
Conclusions: After a minimum duration of follow-up of ten years, there were no significant differences between the two
groups with regard to implant survivorship, functional outcome, knee motion, or prevalence of osteolysis.
Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

T
he high-flexion total knee arthroplasty system was intro- flexion total knee arthroplasty, even when they had used the same
duced to increase the articular surface area at high flexion or a similar implant type2-10. Although there is some information
angles and increase posterior femoral translation and knee about the early performance of high-flexion total knee arthro-
motion. It was postulated that improved tibiofemoral contact at plasty, there is none, to our knowledge, about the mid-term per-
high flexion could decrease contact surface stress and subsequently formance of this prosthesis. The question thus arises as to whether,
decrease osteolysis and wear of the tibial polyethylene component. in the longer term, use of a high-flexion total knee prosthesis
There are conflicting reports of the early results of the high- improves implant longevity, knee function, and knee motion while
flexion total knee prosthesis1-10. Han et al.1 reported a disturbingly decreasing polyethylene wear and osteolysis compared with the
high prevalence of early femoral component loosening after high- same parameters after use of a conventional prosthesis.
flexion total knee arthroplasty. However, authors of other recent The purpose of this study was to evaluate the mid-term
follow-up studies reported excellent early results following high- results of high-flexion and conventional knee prostheses, with a

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this
work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is
written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2012;94:1378-84 d http://dx.doi.org/10.2106/JBJS.K.01229

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particular emphasis on implant survivorship, knee function compiled by a research associate who was not part of the operative team and was
11
and motion, and prevalence of osteolysis. blinded to treatment allocation. We obtained the Knee Society knee score and
the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
12
score separately for each knee. We found that it was relatively easy for patients to
Materials and Methods distinguish the degree of pain in each knee. We inquired with regard to the degree
Demographics of stiffness with use of the WOMAC instrument separately for each knee, and it

T he senior author (Y.-H.K.) performed 111 consecutive primary bilateral total

knee arthroplasties in 111 patients (222 knees). Five patients died from un-
related causes and six were followed for less than two years postoperatively.
was again relatively easy for patients to distinguish the degree of stiffness in each
knee. We also asked about function separately for each knee. Although it was
somewhat difficult for patients to distinguish the degree of impairment of the
Therefore, 100 patients (200 knees) were included in the study. The study was function of each knee, on careful questioning they were able to do so. For ex-
registered in ClinicalTrials.gov Protocol Registration System (trial number, NCT ample, when they had difficulty in ascending or descending stairs, they were able
01422642). The study was approved by our institutional review board, and all to specify which knee bothered them more.
patients provided informed consent. Randomization between the use of a NexGen Active knee motion, both with the patient in the supine position and
Legacy Posterior Stabilized-Flex (NexGen LPS-Flex; Zimmer, Warsaw, Indiana) or while weight-bearing, was determined with use of a standard (60-cm) clinical
a NexGen Legacy Posterior Stabilized (NexGen LPS; Zimmer) prosthesis was goniometer before the operation and at the time of the review. The patients were
determined from a sequential pool on the basis of a table of random numbers. asked to extend the knees as much as possible while lying in a supine position to
Each of the 100 patients received a NexGen LPS-Flex prosthesis on one side and measure flexion contracture. They were told to bend the knees as much as
a NexGen LPS prosthesis on the contralateral side as treatment for knee osteo- possible while lying in a supine position and in a squatting position to measure
arthritis. Seventy-five patients (150 knees) were women, and twenty-five patients the flexion angle. Knee motion was measured for all patients on two occasions by
(fifty knees) were men. The mean age of the patients at the time of the arthroplasty two of the authors (Y.-H.K. and J.-S.K.), both of whom were blinded to the type of
was sixty-five years (range, forty-eight to eighty-five years). The mean patient implanted prosthesis. When the measured knee motion differed by >5° between
height (and standard deviation) was 159.2 ± 7.21 cm (range, 145 to 185 cm), and the two observers, the values were averaged and that number was reported.
the mean weight was 65.8 ± 7.9 kg (range, 51 to 93 kg). The mean body mass Interobserver agreement regarding knee motion was 0.95 to 0.99. The knee
index was 26 kg/m2 (range, 24 to 27 kg/m2). Thirty-three patients (33%) had 13
motion was considered to be the arc of motion instead of the flexion angle . The
undergone bilateral arthroscopic debridement previously. level of activity was assessed by using the Tegner and Lysholm activity score .
14

Surgical Technique Radiographic Evaluation

All procedures were performed by the senior author. A bloodless field was ob- Anteroposterior radiographs with the patient standing (including the hip and the
tained with use of a pneumatic tourniquet at a pressure of 250 mm Hg after ankle) and with the patient lying supine, lateral radiographs, and skyline patellar
exsanguination with an Esmarch bandage. In all knees, an anterior midline skin radiographs were made preoperatively and at each follow-up visit and were as-
incision (10 to 12 cm in length) was used, followed by a medial parapatellar sessed for the alignment of the limb (tibiofemoral angle), the position of the
capsular incision, and the femur was prepared before the tibia. The anterior and components, the posterior slope of the tibial component, the level of the joint
posterior cruciate ligaments were excised. Ligament balancing was done, and an line, and the presence and location of radiolucent lines at the bone-cement
11
attempt was made to resect 10 mm of tibial bone to achieve a surface that was interface according to the recommendations of the Knee Society . Antero-
perpendicular to the shaft of the tibia in the coronal plane with 7° of posterior posterior standing radiographs were used to determine any sequential change in
slope in the sagittal plane in both groups. The distal part of the femur was resected the alignment of the limb as a result of polyethylene wear and/or loosening of the
with an attempt to achieve valgus femorotibial alignment in the coronal plane in implant. Supine anteroposterior radiographs were used to determine the presence
both groups. All patellae were resurfaced with use of a polyethylene patellar of a radiolucent line more precisely. Skyline patellar radiographs were examined
prosthesis. All implants were fixed with CMW cement (DePuy, Warsaw, Indiana) for patellar tilt, subluxation, or dislocation. All radiographs were made under
without antibiotics, after pulsed lavage, drying, and pressurization of the cement. fluoroscopic guidance to control rotation of the knee. Radiographic data at the
time of each follow-up were analyzed and recorded by a research associate who
was not part of the operative team. However, this assessment was not blinded to
Pain Management Protocol allocation because the radiographic appearances of the two implants differ.
All patients received intra-articular analgesic cocktail infiltration (200 mg of
0.5% bupivacaine, 10 mg of morphine, 40 mg of methylprednisolone acetate, Computed Tomography Scan Evaluation
and 300 mg of epinephrine [1:1000]), and all received epidural or patient-
At the latest follow-up evaluation, all patients underwent computed tomog-
controlled intravenous analgesia (patient-controlled anesthesia: a morphine bolus
raphy (CT) scanning with a multislice scanner (General Electric LightSpeed
of 1.5 mg, a lockout time of six minutes, and a maximum of 15 mg per hour). The
Plus; GE Healthcare, Milwaukee, Wisconsin) to determine the rotational
epidural catheter was left in place for continuous pain management for forty-
alignment of the components and to assess for osteolysis. The scan sequence
eight hours after the surgery. Pethidine, tramadol, or oxycodone was administered
was between 10 cm above the superior pole of the patella and 10 cm below
after discontinuation of the epidural or patient-controlled intravenous anesthesia.
the tibial tuberosity, using contiguous 2.5-mm slices. Rotational alignment of
the femoral component was determined by measuring the angle between a line
Rehabilitation joining the medial and lateral epicondyles of the femur and one joining the
Starting on the second postoperative day, the patients used a continuous passive posterior margins of the femoral component (Fig. 1-A). Rotational alignment
motion machine for passive knee motion exercise twice daily for thirty minutes each of the tibial component was assessed by measuring the angle between a line
time. On the same day, they started active knee motion exercises and began standing joining the posterior margins of the medial and lateral tibial plateaus and one
at the bedside or walking with crutches or a walker twice daily for thirty minutes each joining the posterior margins of the tibial component (Fig. 1-B). Osteolysis was
time under the supervision of a physical therapist. The patients used crutches or a defined as any nonlinear region of periprosthetic cancellous bone loss with
walker with full weight-bearing for six weeks and used a cane when needed thereafter. delineable margins. One author (Y.-H.K.) examined all CT scans. The intra-
observer kappa statistic for the radiographic and CT examinations was 0.94.
Clinical Evaluation
Clinical evaluations were done at three months after the operation, at one year, Statistical Analysis
and then yearly thereafter. The mean duration of follow-up was 10.3 years (range, An a priori power calculation was performed with use of a clinically relevant
ten to 10.6 years). All clinical data at the time of each follow-up were recorded and difference in range of motion of 5° and a standard deviation of 10°. Calculations
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TABLE I Clinical Results

Preoperative Final Follow-up

NexGen LPS NexGen LPS-Flex P Value* NexGen LPS NexGen LPS-Flex P Value*

Mean Knee Society knee

score (range) (points)
Total knee score 25 (4-47) 28 (4-44) 0.8431* 93 92 0.8681*
Function score 50.1 (27-68) 50.1 (28-68) 1.000* 85 82 0.8329*
Pain score 0 0 45 43 0.641†
Degree of pain (no. [%]
of knees)
None — — 75 (75%) 71 (71%)
Mild — — 25 (25%) 28 (28%)
Moderate 10 (10%) 14 (14%) — 1 (1%)
Severe 90 (90%) 86 (86%) — —
Mean WOMAC score 65.2 67.3 0.912* 28.9 32.3 0.931*
(points)
Mean activity 1.6 1.7 0.989* 5.7 5.9 0.972*
score (points)

*Paired t test. †Chi-square test.

revealed that, for an effect size of 20% in functional outcome as measured with tion, WOMAC scores, and activity scores were evaluated with a paired t test.
a validated instrument such as the linear analog scale assessment and with a = Complication rates and radiographic data were compared between the two
0.05 and b = 0.80, ninety patients would be needed in each group. In addition groups with use of a paired t test as well. All statistical analyses were performed
to the required number of subjects, ten more patients were recruited to allow with a two-tailed t test. The level of significance was set at p < 0.05. Survivorship
for possible attrition. The changes in the Knee Society knee scores, knee mo- analysis was performed to determine the cumulative rate of survival of the

Fig. 1-A Fig. 1-B

Figs. 1-A and 1-B Postoperative CT scans of a fifty-five-year-old woman with osteoarthritis. Fig. 1-A Measurement of axial rotation of the femoral component in
relation to the transepicondylar axis (AA) and the posterior margins of the femoral component (BB). Fig. 1-B Measurement of axial rotation of the tibial
component in relation to the posterior margins of the medial and lateral tibial plateaus (AA) and one joining the posterior margins of the tibial component (BB).
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TABLE II Total Arc of Knee Motion*

Preoperative One Year Five Years Ten Years

Non-Weight- Non-Weight- Non-Weight- Non-Weight-

Bearing Weight-Bearing Bearing Weight-Bearing Bearing Weight-Bearing Bearing Weight-Bearing

NexGen LPS 128 (75-150) 113 (70-135) 131 (90-145) 116 (75-130) 132 (90-140) 117 (75-130) 133 (90-140) 118 (75-130)
NexGen LPS-Flex 125 (80-150) 110 (80-130) 132 (85-150) 119 (70-130) 133 (70-135) 120 (70-135) 135 (80-140) 121 (70-135)
P value 0.141 0.831 0.231 0.265 0.516 0.567 0.191 0.182
(paired t test)

*The values are given, in degrees, as the mean with the range in parentheses.

15
implant during the period of the study and reported with 95% confidence knee score was 93 points (range, 75 to 100 points) and the Knee
intervals (CI). The end point for the analysis was aseptic loosening and revision Society function score was 85 points (range, 60 to 100 points). In
surgery for any reason.
the NexGen LPS-Flex group, the mean postoperative Knee So-
Source of Funding ciety total knee score was 92 points (range, 70 to 100 points) and
There was no external funding source for this study. the Knee Society function score was 82 points (range, 71 to 100
points) (Table I).
Results
Clinical Results Pain
Knee Score The postoperative Knee Society pain scores did not differ signif-

T he Knee Society total knee scores did not differ significantly

between the two groups either preoperatively (p = 0.8431;
paired t test) or postoperatively (p = 0.8681; paired t test). In the
icantly between the groups (p = 0.641) (Table I). Of the 100 knees
treated with the NexGen LPS implant, seventy-five (75%) were
not painful at the time of the latest follow-up, twenty-five (25%)
NexGen LPS group, the mean postoperative Knee Society total were mildly painful, and none were moderately or severely painful.

TABLE III Radiographic Results

Parameters NexGen LPS NexGen LPS-Flex P Value (Paired T Test)

Alignment* (deg)
Preoperative 13.1 varus (8-23 varus) 12.9 varus (6-21 varus) 0.781
Postoperative 5.5 valgus (2-7 valgus) 5.7 valgus (3-7 valgus) 0.932
Femoral component position (femoral angle)* (deg)
Coronal 97 (89-102) 98 (93-103) 0.959
Sagittal 0.3 (25-7) 0.2 (27-9) 0.643
Tibial component position* (tibial angle) (deg)
Coronal 87 (85-91) 88 (83-92) 0.782
Sagittal 85 (79-89) 83 (81-92) 0.851
Posterior slope of tibial component* (deg) 2 (0-4) 3 (0-5) 0.131
Joint line level* (mm)
Preoperative 16 (11-25) 17 (9-27) 0.717
Postoperative 15 (9-27) 14 (9-26) 0.521
Posterior condylar offset* (mm)
Preoperative 25 (17-32) 24 (18-33) 0.821
Postoperative 24 (19-32) 24 (17-32) 0.869
Radiolucent lines <1 mm (no. [%] of knees)
11
Femoral side: zone 1 5 (5%) 9 (9%)
11
Tibial side: zone 1 7 (7%) 9 (9%)
Osteolysis (no. [%] of knees) 0 (0%) 0 (0%)

*The values are given as the mean with the range in parentheses.
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WOMAC Score
In both groups, the preoperative WOMAC scores (65.2 and
67.3 points) were found to be significantly improved at the time
of latest follow-up (28.9 and 32.3 points) (Table I).

Activity Score
The preoperative activity scores of Tegner and Lysholm (1.6
and 1.7 points) were also improved significantly at the time
of latest follow-up (5.7 and 5.9 points) in both groups
(Table I).

Range of Motion
Preoperatively, the mean knee flexion contracture was 15°
(range, 0° to 50°) in the NexGen LPS group and 14° (range, 0° to
50°) in the NexGen LPS-Flex group. Eighty-nine patients (89%)
had a notable (10° or greater) flexion contracture preoperatively.
At one year, no knee had a measurable flexion contracture. The
mean ranges of flexion in supine and squatting positions pre-
operatively, at one year, at five years, and at ten years did not
differ significantly between the two groups (p = 0.381) (Table II).

Satisfaction
Seventy-five patients (75%) were fully satisfied and twenty-five
patients (25%) were satisfied with the outcome of the operation
with the NexGen LPS prosthesis. Seventy-two patients (72%)
Fig. 2-A were fully satisfied with the NexGen LPS-Flex prosthesis, twenty-
Figs. 2-A and 2-B Radiographs of both knees of a sixty-six-year-old woman seven patients (27%) were satisfied, and one (1%) was dissat-
with osteoarthritis made at ten years after surgery. Fig. 2-A Antero- isfied because of constant moderate pain. Eighty-seven patients
posterior radiograph revealing that the NexGen LPS (right) and the (87%) had no preference, seven patients (7%) preferred the
NexGen LPS-Flex (left) prostheses are embedded rigidly. No radiolucent NexGen LPS prosthesis, and six patients (6%) preferred the
lines or osteolysis are demonstrated around the tibial components in NexGen LPS-Flex prosthesis. Preference of one knee over
either knee, and no gross wear of the polyethylene tibial insert is visu- the other knee was determined by stiffness of one knee.
alized in either knee.
Radiographic Results
Of the 100 knees treated with the NexGen LPS-Flex prosthesis, There were no significant differences between the two groups with
seventy-one (71%) were not painful, twenty-eight (28%) were regard to the alignment of the knee, the position of the femoral
mildly painful, one (1%) was moderately painful, and none and tibial components in the coronal and sagittal planes, the
were severely painful. posterior slope of the tibial component, the joint line, or the

Fig. 2-B
Lateral radiographs showing the absence of radiolucent lines or osteolysis around the femoral, tibial, and patellar components in both knees.
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amount of the tibial surface area covered by the implants (tibial was no evidence proving the superiority of the NexGen LPS-
capping). The alignment of the knee was a mean of 5.5° of Flex prosthesis over the NexGen LPS prosthesis. We believe that
valgus in the NexGen LPS group and 5.7° of valgus in the the excellent results of the NexGen LPS-Flex and NexGen LPS
NexGen LPS-Flex group. No knee in either group had tibial, prostheses are attributable to adequate support of the anterior
femoral, or patellar osteolysis (Table III). and posterior femoral condyles due to accurate bone cuts, rela-
tively good bone quality, and good cementing technique.
CT Evaluation There are inconsistencies regarding the reported differ-
The CT scans showed no significant difference in external ro- ences in the range of knee motion between patients with a high-
tation of the femoral or tibial components between the two flexion knee prosthesis and those with a conventional knee
designs. The CT scans showed no tibial, femoral, or patellar prosthesis. Several authors2,18,19 found that patients with a high-
osteolysis in either group. flexion knee prosthesis gained notably more knee motion than
those with a conventional knee prosthesis. However, others3,10
Complications did not find a difference in knee motion between the high-
The complication rate was low and was similar in the two groups. flexion and conventional knee components. In the current
One knee in each group exhibited deep infection. Both knees study, maximal flexion in the group with a NexGen LPS-Flex
were treated with open debridement, followed by intravenous component was similar to that in the group with a NexGen LPS
antibiotics for six weeks. There was no recurrence of infection in component. The NexGen LPS-Flex component did not dem-
the knee in the NexGen LPS group, but infection recurred in the onstrate its theoretical advantage of providing a better range
knee in the NexGen LPS-Flex group; that knee was subsequently of motion of the knee. Therefore, we believe that other factors
treated with a two-stage revision total knee arthroplasty. such as a good preoperative range of motion, flexion space bal-
ancing, posterior tibiofemoral articular contact stability, limb
Survivorship Analysis characteristics (long and slender versus short and thick), and the
Kaplan-Meier survivorship15 analysis, with revision defined as patient’s motivation may have affected the range of knee motion.
the end point, showed a 100% implant-survival rate for the All of the patients in both groups in the current study had an
NexGen LPS prosthesis (95% CI, 94 to 100) and a 99% rate for improvement in knee function as assessed with the Knee Society
the NexGen LPS-Flex prosthesis (95% CI, 93 to 100) at ten knee function score and the WOMAC score.
years postoperatively. With aseptic loosening as the end point, Several authors have suggested that the articulating surface
the survival rate was 100% (95% CI, 95 to 100) in both groups of the high-flexion femoral component is much more con-
at ten years postoperatively (Fig. 2). forming at a high flexion angle than is the conventional total knee
design4,6,20. Therefore, they suggested that the high-flexion total
Discussion knee designs decrease stress concentration on the polyethylene

T he NexGen LPS-Flex total knee system was introduced to

enhance knee flexion and to decrease wear of tibial poly-
ethylene after total knee arthroplasty. Compared with the NexGen
surface and lead to decreased wear and less osteolysis in patients
who attain high flexion. In contrast, the authors of another
study21 reported that all high-flexion knee prostheses could result
LPS prosthesis, the NexGen LPS-Flex total knee system includes in almost point contact in an extremely high range of motion.
an extension of the posterior condyle of the femoral component The absence of osteolysis in both the NexGen LPS-Flex and the
by 2 mm, a modification of the cam and tibial spine, and a re- NexGen LPS group in our study may be related to a prepon-
duction of patellar impingement. The purpose of an extended derance of female patients, the use of solid locking of the tibial
posterior condyle of the femoral component is to extend the baseplate to reduce backside wear of the insert, a compression-
surface of the femoral component posteriorly to increase the ar- mold polyethylene tibial insert sterilized with gamma-radiation
ticular contact area at high flexion angles and to increase posterior in inert gas, and the short shelf life of the tibial insert. It is possible
femoral translation and knee flexion. Furthermore, an improved that the follow-up was not sufficiently long to reveal osteolysis.
tibiofemoral contact environment at high flexion angles could The concept that a NexGen LPS-Flex prosthesis is associated with
theoretically decrease the contact surface stress on the tibial less wear and a lower prevalence of osteolysis than a NexGen LPS
polyethylene and potentially decrease wear of the tibial poly- prosthesis remains to be proven in a longer-term follow-up study.
ethylene. Moreover, the femoral cam design increases the contact There are several strengths of this study. First, evaluating
surface between the cam and the tibial spine beyond that of patients treated by a single surgeon at a single center means that
the standard design at flexion angles of >130° and thereby may there was consistency in surgical technique and implant use in
decrease the wear of the polyethylene tibial post and the rate the study. Second, the follow-up was long enough to determine
of osteolysis. However, in this study, the survivorship, knee the functional outcome, survivorship, prevalence of osteolysis,
function, knee motion, and prevalence of osteolysis were similar and loosening. Finally, activity level data were collected and can
between the two groups. be analyzed as a risk factor for failure.
Several authors1,16,17 reported that the high-flexion knee This study also had some limitations. First, we did not
prosthesis had a higher risk of loosening at high flexion angles. assess interobserver variability in the radiographic and CT scan-
In the current study, the ten-year survivorship of the NexGen ning measurements. However, we did determine the intraobserver
LPS and NexGen LPS-Flex prostheses was excellent, but there agreement of the radiographic and CT scanning measurements22.
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Second, it is frequently difficult for a patient who has under- NexGen LPS-Flex prosthesis (particularly in patients with
gone bilateral total knee arthroplasty to distinguish the func- small bones) may affect femoral component fixation and may
tion of one knee from that of the other. Therefore, the be a concern should revision arthroplasty be necessary. n
WOMAC function scores should be interpreted with caution
because it is difficult for patients to attribute functional status
to a particular knee.
After a minimum duration of follow-up of ten years, we
found no significant differences between these two groups with Young-Hoo Kim, MD
regard to survivorship, functional outcome, knee motion, or Jang-Won Park, MD
prevalence of osteolysis. Although the present study does not Jun-Shik Kim, MD
The Joint Replacement Center,
clearly direct the surgeon toward either arm of treatment, we Ewha Womans University MokDong Hospital,
believe that the extra bone that was removed from the posterior 911-1, MokDong, YangChun-Ku,
femoral condyles and intercondylar notch to allow for the Seoul, South Korea 158-710.
thicker posterior femoral condyles and the femoral cam in the E-mail address for Y.-H. Kim: younghookim@ewha.ac.kr

References
1. Han HS, Kang SB, Yoon KS. High incidence of loosening of the femoral compo- 12. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation
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