CEMENTLESS FIXATION: ALL CEMENTED COMPONENTS VS. HYBRID FIXATION (CEMENTLESS FEMORAL COMPONENT)

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.