ICJR REWIND: Tips for Preventing Tibial Loosening in Total Knee Arthroplasty

    Aseptic tibial loosening is the number 1 cause of failure leading to revision after total knee arthroplasty (TKA). [1]

    That shouldn’t be the case: At the 7th Annual ICJR South Hip & Knee Course, Daniel J. Berry, MD, from Mayo Clinic in Rochester, Minnesota, said that surgeons know more now about how to cement knee implants than they did even 15 years ago and have – theoretically – gotten better at it.

    But the data suggest, he said, that surgeons have actually become worse at cementing knee implants. They’re rushing through the procedure, he said, using the wrong type of cement and the wrong cementing technique.

    So, there’s a lot of room for improvement, and surgeons can do better by focusing on:

    • Good alignment
    • Good cementing technique
    • Appropriate cement choice
    • Implant choice
    • Identification and management of high-risk patients

    At the implant-cement interface, Dr. Berry said, the surgeon should:

    • Avoid debonding
    • Coat the implant before inserting it into the cement mantle
    • Use early-phase cement
    • Use low-viscosity cement, which creates a better bond on metal than high-viscosity cement

    At the bone-cement interface, the surgeon should cement the entire implant, not just the surface. Cementing the keel will increase interface strength 150%, Dr. Berry said. [2]

    In addition, surgeons should be careful to interdigitate the cement to the bone. Hold the implant still until the cement has hardened: Even a little motion at the end of the hardening process can cause debonding, Dr. Berry said.

    Click the image above to watch Dr. Berry’s presentation and learn more about cement technique in TKA.

    This article was originally published on November 4, 2019.

    Disclosures: Dr. Berry has disclosed that he received royalties from DePuy Synthes.


    1. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2019 Annual Report. Adelaide: AOA, 2019.
    2. Billi F, Kavanaugh A, Schmalzried H, Schmalzried TP. Techniques for improving the initial strength of the tibial tray-cement interface bond. Bone Joint J. 2019 Jan;101-B(1_Supple_A):53-58. doi: 10.1302/0301-620X.101B1.BJJ-2018-0500.R1.