Moderate evidence supports the use of either cementing all components or hybrid fixation (cementless femur) in total knee arthroplasty due to similar functional outcomes and rates of complications and reoperations.

There were five high (Lizaur-Utrilla 2014, Kim 2014, Beaupre 2007, Demey 2011, Fernandez-Fairen 2013) and seven moderate quality (Park 2011, Khaw 2002, Carlsson 2005, Baker 2007, Pandit 2013, Parker 2001, Pulido 2015) studies evaluating the use of various combinations of cemented versus cementless component (tibia, femur, patella) fixation in knee arthroplasty.

The overall body of evidence was notable for heterogeneity in study design and comparative study groups (including cementless, hybrid, and cemented fixation).   Nevertheless, across comparative groups, no major differences existed between cemented and cementless fixation with respect to rates of complications and re-operations, including studies with longer follow up (Khaw 2002, Baker 2007, Kim 2014).  

Only small differences were seen with respect to outcome measures, depending on the particular study comparative groups, length of follow up, and scoring instruments.  Lizaur-Utrilla found no significant differences in WOMAC scores at follow-up time points of two years or less when comparing cemented and cementless tibial fixation (with cementless femoral fixation and selective patellar resurfacing in both arms). WOMAC scores were significantly better in the uncemented (porous) tibial group (-5[-9.49,-0.51]) at final follow up (average 7 years), but this difference was not clinically significant.  Knee Society function scores were significantly better in the uncemented tibial group only at the 2 year follow up (-4[-7.62,-0.38]). Knee Society pain scores were significantly better at 2 years (-3 [-5.58, -0.42]) and at final follow up (-3 [-5.68, -0.32]), but not at 6 months or one year.  In a study comparing cemented and cementless tibial fixation (with cementless femoral fixation and selective patellar resurfacing in both arms), 
Beaupré reported that WOMAC pain and RAND SF-36 bodily pain scores were significantly worse in the group with cementless hydroxyapatite-coated tibial components (9.1[2.79,15.41] versus 18.1[9.66,26.54] for cemented fixation)at 6 months. The differences in pain did not remain statistically significant at 1 or 5 years post-operatively. Fernandez-Fairen found that WOMAC scores were worse in the cemented tibial fixation group compared to scores in the cementless tibial fixation group (cementless femoral fixation and no patellar resurfacing in both arms), with a difference of 4 points (CI 0.13, 7.87) that was not clinically significant.  When comparing non-modular cemented tibial components with non-modular cementless porous tibial components, Pulido demonstrated more improvement in Knee Society pain scores (5 [0.08, 9.92]) in the cemented tibial group, but this difference was not clinically significant.  In a study of unicompartmental knee arthroplasty patients implanted with either cemented or cementless femoral/tibial fixation, Pandit reported significantly worse Knee Society function scores at 5 years (-12.2[-20.26,-4.14]), but not at 1 or 2 years, for the cemented group.  Tegner Activity Scores in the cemented group were significantly worse at 2 years (-0.6[-1.10,-0.10]), but not at 1 or 5 years.

More data is needed in particular patient subgroups, such as young and active patients, or those patients with poor bone quality.  Of note, two of the included controlled trials enrolled patients only 55 years of age and younger (Lizaur-Utrilla 2014, Kim 2014).  Likewise, the management of the patella varied across studies, and often between groups within a single study, including use of cemented fixation, selective resurfacing, and unresurfaced patellae.  More historical studies highlighting cementless tibia failure modes were largely excluded either due to poor study quality or date of publication.  The study by Parker noted worse Kaplan-Meier survivorship in patients with a metal-backed patella, and rates of metal-backed patella failure were particularly worse in the cementless fixation (tibial/ femoral) group when compared to patients with cemented fixation.

The practitioner should be aware that results in the literature may be implant- and design-specific, and that surgical technique and surgeon experience with particular fixation methods is important in achieving durable results.  Study quality was adjusted for those studies in whom authors had conflicts of interest with implant manufacturers.  
  1. Baker,P.N., Khaw,F.M., Kirk,L.M., Esler,C.N., Gregg,P.J. A randomised controlled trial of cemented versus cementless press-fit condylar total knee replacement: 15-year survival analysis. J Bone Joint Surg Br 2007/12; 12: 1608-1614
  2. Beaupre,L.A., al,Yamani M., Huckell,J.R., Johnston,D.W. Hydroxyapatite-coated tibial implants compared with cemented tibial fixation in primary total knee arthroplasty. A randomized trial of outcomes at five years. The Journal of bone and joint surgery.American volume 2007; 0: 2204-2211
  3. Carlsson,A., Bjorkman,A., Besjakov,J., Onsten,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 2005/6; 3: 362-369
  4. Demey,G., Servien,E., Lustig,S., Ait Si,Selmi T., Neyret,P. Cemented versus uncemented femoral components in total knee arthroplasty. Knee Surg Sports Traumatol.Arthrosc. 2011/7; 7: 1053-1059
  5. Fernandez-Fairen,M., Hernandez-Vaquero,D., Murcia,A., Torres,A., Llopis,R. Trabecular metal in total knee arthroplasty associated with higher knee scores: a randomized controlled trial. Clin Orthop Relat Res. 2013/11; 11: 3543-3553
  6. Khaw,F.M., Kirk,L.M., Morris,R.W., Gregg,P.J. A randomised, controlled trial of cemented versus cementless press-fit condylar total knee replacement. Ten-year survival analysis. J Bone Joint Surg Br 2002/7; 5: 658-666
  7. Kim,Y.H., Park,J.W., Lim,H.M., Park,E.S. Cementless and cemented total knee arthroplasty in patients younger than fifty five years. Which is better?. Int Orthop 2014/2; 2: 297-303
  8. Lizaur-Utrilla,A., Miralles-Munoz,F.A., Lopez-Prats,F.A. Similar survival between screw cementless and cemented tibial components in young patients with osteoarthritis. Knee Surg.Sports Traumatol.Arthrosc. 2014/7; 7: 1585-1590
  9. Pandit,H., Liddle,A.D., Kendrick,B.J.L., Jenkins,C., Price,A.J., Gill,H.S., Dodd,C.A.F., Murray,D.W. Improved fixation in cementless unicompartmental knee replacement: Five-year results of a randomized controlled trial. Journal of Bone and Joint Surgery - Series A 2013; 15: 1365-1372
  10. Park,J.W., Kim,Y.H. Simultaneous cemented and cementless total knee replacement in the same patients: a prospective comparison of long-term outcomes using an identical design of NexGen prosthesis. J Bone Joint Surg Br 2011/11; 11: 1479-1486
  11. Parker,D.A., Rorabeck,C.H., Bourne,R.B. Long-term followup of cementless versus hybrid fixation for total knee arthroplasty. Clin Orthop Relat Res. 2001/7; 388: 68-76
  12. Pulido,L., Abdel,M.P., Lewallen,D.G., Stuart,M.J., Sanchez-Sotelo,J., Hanssen,A.D., Pagnano,M.W. The mark coventry award : trabecular metal tibial components were durable and reliable in primary total knee arthroplasty: a randomized clinical trial. Clin Orthop Relat Res 2015/1; 1: 34-42