In general, the body of evidence was notable for heterogeneity in study design and comparative study groups (including cementless, hybrid, and cemented fixation). As such, the recommendation has been downgraded.
There were twelve high quality studies (Demey 2011, Fernandez-Fairen 2013, Kim 2014, Lizaur-Utrilla 2014, Kendrick 2015, Pulido 2015, Van Hamersveld 2017, Nam 2019, Batailler 2020, Hampton 2020, Kim 2020, Murylev 2020) and seventeen low quality (Khaw 2002, Carlsson 2005, Baker 2007, Park 2011, Pandit 2013, Bagsby 2016, Kerens 2017, Boyle 2018, Nugent 2019, Manoli 2019, Deroche 2020, Irmola 2020, Lizaur-Utrilla 2020, Mohammad 2020, Gifstad 2021, Silverstein 2021, Quispel 2021) evaluating the use of various combinations of cemented versus cementless fixation of components (tibia, femur, patella) in total knee arthroplasty.
One high quality (Batailler 2020) and four low quality studies (Nugent 2019, Irmola 2020, Lizaur-Utrilla 2020, Quispel 2021) specifically compared cemented and hybrid fixation. Nugent (2019) showed significantly better functional outcomes and lower rates of revision with all cemented fixation, and Lizaur-Utrilla (2020) showed significantly better functional outcomes and lower rates of revision with hybrid fixation. Additional low quality studies showed no significant difference in revision rates between the two fixation types. Like the cemented versus cementless comparisons, only small differences were seen with respect to outcome measures, depending on the particular study comparative groups, length of follow up, and scoring instruments.
Benefits/ Harms of Implementation
There are no known harms associated with implementing this recommendation. The decision to use cementless versus cementless fixation may be influenced by particular patient situations. The practitioner should be aware of the advantages and disadvantages of particular treatments methods. For example, intra-operative fracture during component insertion or failure of ingrowth may be of concern with certain cementless designs in patients with poor bone quality.
Future Research
Continued long term comparative studies between modern cemented and cementless component fixation options in knee arthroplasty will help to further define the utility of these component types, durability of fixation, and effect of evolving component designs (e.g., modular and monolithic) on patient-reported outcomes. Certainly, newer fixation materials (e.g., porous metals) should be evaluated in long term follow up. Identifying patient-specific factors that may inform the decision to utilize a particular fixation technique, or to avoid complications associated with particular fixation strategies, is important. Registry data and long-term studies (greater than ten years clinical follow up) should inform durability of particular components and may serve to analyze implant-specific complications and revision risk. Given some variability in the patient-reported outcome measures between treatment groups, particularly in high quality studies, more clinical data may discern subtle differences in clinical outcomes based on the use of cemented or cementless component fixation. Issues of cost and cost-effectiveness should also be incorporated into future clinical studies.
- Bagsby, D. T., Issa, K., Smith, L. S., Elmallah, R. K., Mast, L. E., Harwin, S. F., Mont, M. A., Bhimani, S. J., Malkani, A. L. Cemented vs Cementless Total Knee Arthroplasty in Morbidly Obese Patients. Journal of Arthroplasty 2016; 8: 1727-1731
- 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. Journal of Bone & Joint Surgery - British Volume 2007; 12: 1608-14
- Batailler, C., Malemo, Y., Demey, G., Kenney, R., Lustig, S., Servien, E. Cemented vs Uncemented Femoral Components: A Randomized, Controlled Trial at 10 Years Minimum Follow-Up. Journal of Arthroplasty 2020; 8: 2090-2096
- Boyle, K. K., Nodzo, S. R., Ferraro, J. T., Augenblick, D. J., Pavlesen, S., Phillips, M. J. Uncemented vs Cemented Cruciate Retaining Total Knee Arthroplasty in Patients With Body Mass Index Greater Than 30. Journal of Arthroplasty 2018; 4: 1082-1088
- Carlsson, A., Björkman, 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 Orthopaedica 2005; 3: 362-9
- Demey, G., Servien, E., Lustig, S., Aït Si Selmi, T., Neyret, P. Cemented versus uncemented femoral components in total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 2011; 7: 1053-9
- Deroche, E., Martres, S., Ollivier, M., Gadeyne, S., Wein, F., Gunepin, F. X., Remy, F., Badet, R., Lustig, S., la, Sfhg Excellent outcomes for lateral unicompartmental knee arthroplasty: Multicenter 268-case series at 5 to 23 years' follow-up. Orthopaedics & traumatology, surgery & research 2020; 5: 907-913
- Fernandez-Fairen, M., Hernández-Vaquero, D., Murcia, A., Torres, A., & Llopis, R. (2013). Trabecular metal in total knee arthroplasty associated with higher knee scores: a randomized controlled trial. Clinical Orthopaedics and Related Research®, 471(11), 3543-3553.
- Gifstad, T., Nordskar, J. J., Egeberg, T., Wik, T. S., Winther, S. B. Cementless unicompartmental knee arthroplasty results in higher pain levels compared to the cemented technique: a prospective register study. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2021; 0:
- Hampton, M., Mansoor, J., Getty, J., Sutton, P. M. Uncemented tantalum metal components versus cemented tibial components in total knee arthroplasty: 11- to 15-year outcomes of a single-blinded randomized controlled trial. Bone & Joint Journal 2020; 8: 1025-1032
- Irmola, T., Ponkilainen, V., Makela, K. T., Robertsson, O., W. Dahl A, Furnes, O., Fenstad, A. M., Pedersen, A. B., Schroder, H. M., Eskelinen, A., Niemelainen, M. J. Association between fixation type and revision risk in total knee arthroplasty patients aged 65 years and older: a cohort study of 265,877 patients from the Nordic Arthroplasty Register Association 2000-2016. Acta Orthopaedica 2020; 0: 1-6
- Kendrick, B. J., Kaptein, B. L., Valstar, E. R., Gill, H. S., Jackson, W. F., Dodd, C. A., Price, A. J., Murray, D. W. Cemented versus cementless Oxford unicompartmental knee arthroplasty using radiostereometric analysis: a randomised controlled trial. Bone & Joint Journal 2015; 2: 185-91
- Kerens, B., Schotanus, M. G. M., Boonen, B., Boog, P., Emans, P. J., Lacroix, H., Kort, N. P. Cementless versus cemented Oxford unicompartmental knee arthroplasty: early results of a non-designer user group. Knee Surgery, Sports Traumatology, Arthroscopy 2017; 3: 703-709
- 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. Journal of Bone & Joint Surgery - British Volume 2002; 5: 658-66
- Kim, Y. H., Park, J. W., Jang, Y. S. The 22 to 25-Year Survival of Cemented and Cementless Total Knee Arthroplasty in Young Patients. Journal of Arthroplasty 2020; 0: 06
- 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?. International Orthopaedics 2014; 2: 297-303
- Lizaur-Utrilla, A., Miralles-Muñoz, F. A., Lopez-Prats, F. A. Similar survival between screw cementless and cemented tibial components in young patients with osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy 2014; 7: 1585-90
- Lizaur-Utrilla, A., Miralles-Munoz, F. A., Ruiz-Lozano, M., Gonzalez-Parreno, S., Alonso-Montero, C., Lopez-Prats, F. A. Better clinical outcomes and overall higher survival with hybrid versus cemented primary total knee arthroplasty: a minimum 15 years follow-up. Knee Surgery, Sports Traumatology, Arthroscopy 2020; 0: 28
- Manoli, A., 3rd, Markel, J. F., Pizzimenti, N. M., Markel, D. C. Early Results of a Modern Uncemented Total Knee Arthroplasty System. Orthopedics 2019; 6: 355-360
- Mohammad, H. R., Matharu, G. S., Judge, A., Murray, D. W. Comparison of the 10-year outcomes of cemented and cementless unicompartmental knee replacements: data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Acta Orthopaedica 2020; 1: 76-81
- Murylev, V. Y., Muzychenkov, A. V., Zhuchkov, A. G., Tsygin, N. A., Rigin, N. V., Elizarov, P. M., Kukovenko, G. A. Functional outcomes comparative analysis of cemented and uncemented total knee arthroplasty. Journal of Orthopaedics 2020; 0: 268-274
- Nam, D., Lawrie, C. M., Salih, R., Nahhas, C. R., Barrack, R. L., Nunley, R. M. Cemented Versus Cementless Total Knee Arthroplasty of the Same Modern Design: A Prospective, Randomized Trial. Journal of Bone & Joint Surgery - American Volume 2019; 13: 1185-1192
- Nugent, M., Wyatt, M. C., Frampton, C. M., Hooper, G. J. Despite Improved Survivorship of Uncemented Fixation in Total Knee Arthroplasty for Osteoarthritis, Cemented Fixation Remains the Gold Standard: An Analysis of a National Joint Registry. Journal of Arthroplasty 2019; 8: 1626-1633
- Pandit, H., Liddle, A. D., Kendrick, B. J., Jenkins, C., Price, A. J., Gill, H. S., Dodd, C. A., Murray, D. W. Improved fixation in cementless unicompartmental knee replacement: five-year results of a randomized controlled trial. Journal of Bone & Joint Surgery - American Volume 2013; 15: 1365-72
- 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. Journal of Bone & Joint Surgery - British Volume 2011; 11: 1479-86
- 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. 2015; 1: 34-42
- Quispel, C. R., van Egmond, J. C., Bruin, M. M., Spekenbrink-Spooren, A., Verburg, H., Pasma, J. H. No effect of fixation type on early and late mortality after total knee arthroplasty: a Dutch arthroplasty register study. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2021; 0:
- Silverstein, R. S., Owashi, E. T., Rawicki, N. L., Patel, N. R., Shatkin, M. S., Zelicof, S. B. Retrospective matched case-control study evaluating cementless total knee replacements in patients with BMI over 30 kg/m2or in patients aged 65 yr and younger. Current Orthopaedic Practice 2021; 5: 495-499
- van Hamersveld, K. T., Marang-van de Mheen, P. J., Tsonaka, R., Valstar, E. R., Toksvig-Larsen, S. Fixation and clinical outcome of uncemented peri-apatite-coated versus cemented total knee arthroplasty : five-year follow-up of a randomised controlled trial using radiostereometric analysis (RSA). Bone & Joint Journal 2017; 11: 1467-1476