CEMENTLESS FIXATION: ALL CEMENTLESS COMPONENTS VS. HYBRID FIXATION (CEMENTLESS TIBIAL COMPONENT)

In general, the body of evidence was notable for heterogeneity in study design, comparative study groups (including cementless, hybrid, and cemented fixation), and confounding results. 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) studies evaluating the use of various combinations of cemented versus cementless fixation of components (tibia, femur, patella) in total knee arthroplasty.

Three low quality studies (Nugent 2019, Irmola 2020, Quispel 2021) compared cementless and hybrid fixation. Irmola (2020) and Nugent (2019) showed significantly lower total revision rates in the hybrid group, but no difference in specific indications. Nugent (2019) showed statistically significantly better Oxford knee scores at 6 months postoperative in the hybrid fixation group, but no difference at 5 and 10 years.

Only one study (Irmola 2020) compared hybrid fixation to inverse hybrid (cemented femoral component and uncemented tibial component), finding no difference in revisions at 5 years.

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 reported patient-reported outcome measures between treatment groups in particular 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.