Cementless Fixation: A New Gold Standard for TKA?

    While acknowledging that cementless total knee arthroplasty (TKA) is a controversial topic, H. Del Schutte Jr., MD, asked attendees at the 8th Annual ICJR Winter Hip & Knee Course, “If you could get the same results in total knee arthroplasty without cement, spending less OR time, and also get increased longevity of the prosthesis – would you?”

    Dr. Schutte, from the Joint Replacement Center at East Cooper Medical Center in Mount Pleasant, South Carolina, said that early studies of cementless TKA showed a significant number of failures due to failure of bony ingrowth – 13% in a 2000 presentation by Fehring et al at the annual meeting of the American Association of Hip and Knee Surgeons. But most of those results pertained to 20-year-old prosthesis designs.

    Even with newer designs, there are concerns about failure of fixation, slower rehabilitation, use of a metal-backed patella, more difficult revisions, and a risk of unexplained persistent postoperative pain.

    But cement creates its own set of complications, Dr Schutte said, such as cement disease and increased polyethylene wear due to cement particles in the joint space.

    Dr. Schutte lists the following advantages to cementless fixation:

    • Bony ingrowth into a cementless prosthesis provides biologic fixation, which is near-permanent once ingrowth is achieved. A 2013 study by Harwin et al [1] found 0% loosening at 3 years of follow-up using a cementless posterior stabilized prosthesis.
    • Studies have shown less polyethylene wear with cementless than with cemented prostheses.
    • Cementless TKA requires less time in the OR.
    • Cementless TKA does not require a tourniquet. Avoiding the use of a tourniquet during the procedure can decrease early postoperative pain and nerve injury and improve muscle function, patella tracking, and range of motion in the first postoperative months.
    • Polymethyl methacrylate (PMMA) allergies are more common and more aggressive than metal allergies. Cementless TKA eliminates that concern.

    Newer cementless designs use improved porous foam materials and adjunct surface coatings that provide secure initial fixation and improved bony ingrowth, Dr. Schutte said, concluding that cementless fixation may become the new “gold standard” for fixation in TKA.

    Click the image above to watch Dr. Schutte’s presentation from ICJR’s Winter Hip & Knee Course.


    1. Harwin SF, Kester MA, Malkani AL, Manley MT. Excellent fixation achieved with cementless posteriorly stabilized total knee arthroplasty. J Arthroplasty. 2013 Jan;28(1):7-13. Epub 2012 Jul 31.