Cementless Components Research Articles

Conventionally instrumented inverse kinematic alignment for total knee arthroplasty: How is it done?

For primary total knee arthroplasty (TKA), there is an increasing trend towards patient-specific alignment strategies such as kinematic alignment (KA) and inverse kinematic alignment (iKA), which by restoring native joint mechanics may yield higher patient satisfaction rates. Second, the most recent Australian joint registry report describes favourable revision rates for conventionally instrumented TKA compared to technology-assisted techniques such as those using navigation, robotics or custom-cutting blocks. The aim of this technique article is to describe in detail a surgical technique for TKA that: (1) utilises the principles of iKA and (2) uses conventionally instrumented guided resections thereby avoiding the use of navigation, robotics or custom blocks. A TKA technique is described, whereby inverse kinematic principles are utilised and patient-specific alignment is achieved. Additionally, the patellofemoral compartment of the knee is restored to the native patellofemoral joint line. The sequenced technical note provided may be utilised for cemented or cementless components; cruciate retaining or sacrificing designs and for fixed or rotating platforms. An uncomplicated, robust and reproducible technique for TKA is described. Knee arthroplasty surgeons may wish to harness the emerging benefits of both a conventionally instrumented technique and a patient-specific alignment strategy. Level V.

Registry-based study of survivorship of cemented femoral components versus collared cementless femoral components in total hip arthroplasty in older patients with osteoarthritis.

In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA). Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1 September 1999 to 31 December 2022 were analyzed. Collared cementless femoral components and cemented components were identified, and the three most commonly used components in each group were analyzed. We identified a total of 11,278 collared cementless components and 47,835 cemented components. Hazard ratios (HRs) from Cox proportional hazards models, adjusting for age and sex, were obtained to compare the revision rates between the groups. From six months postoperatively onwards, patients aged ≥ 75 years undergoing primary THA with primary diagnosis of OA have a lower risk of all-cause revision with collared cementless components than with a polished tapered cemented component (HR 0.78 (95% confidence interval 0.64 to 0.96); p = 0.018). There is no difference in revision rate prior to six months. Patients aged ≥ 75 years with a primary diagnosis of OA have a significantly lower rate of revision with the most common collared cementless femoral component, compared with the most common polished tapered cemented components from six months postoperatively onwards. The lower revision rate is largely due to a reduction in revisions for fracture and infection.

A Comparison of the Periprosthetic Fracture Rate of Cemented and Cementless Mobile Bearing Unicompartmental Knee Arthroplasties: An Analysis of Data From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man

BackgroundPeriprosthetic fractures are rare but serious complications of unicompartmental knee arthroplasty (UKA). Although cementless UKA has a lower risk of loosening than cemented, there are concerns that tibial fracture risk may be higher given the reliance on interference fit for primary stability. The risk of fracture and the effect of surgical fixation are currently unknown. We compared the periprosthetic fracture rate following cemented and cementless UKA surgery. MethodsA total of 14,122 medial mobile-bearing UKAs (7,061 cemented and 7,061 cementless) from the National Joint Registry and Hospital Episodes Statistics database were propensity score-matched. Cumulative fracture rates were calculated and Cox regressions were used to compare fixation groups. ResultsThe three-month periprosthetic fracture rates were similar (P = .80), being 0.10% in the cemented group and 0.11% in the cementless group. The fracture rates were highest during the first three months postoperatively, but then decreased and remained constant between one and 10 years after surgery. The one-year cumulative fracture rates were 0.2% (confidence interval [CI]: 0.1 to 0.3) for cemented and 0.2% (CI: 0.1 to 0.3) for cementless cases. The 10-year cumulative fracture rates were 0.8% (CI: 0.2 to 1.3) and 0.8% (CI: 0.3 to 1.3), respectively. The hazard ratio during the whole study period was 1.06 (CI: 0.64 to 1.77; P = .79). ConclusionsThe periprosthetic fracture rate following mobile bearing UKA surgery is low, being about 1% at 10 years. There were no significant differences in fracture rates between cemented and cementless implants after matching. We surmise that surgeons are aware of the higher theoretical risk of early fracture with cementless components and take care with tibial preparation. Levels of evidenceIII.

A Comparison of the Periprosthetic Fracture Rate of Cemented and Cementless Total Knee Arthroplasties: An Analysis of Data From the National Joint Registry

BackgroundPeriprosthetic fractures are serious complications of knee arthroplasty often requiring complex surgery. There is concern of increased periprosthetic fracture risk with cementless components given the reliance on interference fit for primary stability. It is unknown how the periprosthetic fracture risk compares between cemented and cementless total knee arthroplasties (TKAs). MethodsA total of 22,477 cemented and 22,477 cementless TKAs from the National Joint Registry and Hospital Episodes Statistics database were propensity score matched on patient and surgical factors. Cumulative periprosthetic fracture rates were calculated using Kaplan-Meier analyses and compared with Cox regressions. Subgroup analyses were performed in different age, body mass index, and sex groups. ResultsThe 3-month fracture rate in the cemented and cementless TKA groups were 0.02% and 0.04%, respectively. At 10 years, the cumulative fracture rate after cemented TKA was 1.2%, and after cementless was 1.4%. During the study period, there were no significant differences in fracture rates between cemented and cementless TKAs with a hazards ratio 1.14 (confidence interval 0.94 to 1.37, P = .20) at 10 years postoperatively. There were no significant differences in fracture rates between fixation types on subgroup analyses of sex, body mass index, and age groups. Female sex was a risk factor for fracture in both cemented (odds ratio 2.35, P < .001) and cementless TKAs (odds ratio 2.97, P < .001). ConclusionsThe periprosthetic fracture rates following cemented and cementless TKA surgery are low being approximately 1.2% and 1.4%, respectively at 10 years. There were no significant differences in periprosthetic fracture rates requiring readmission between cemented and cementless TKAs. Level of evidenceIII.

Cementless and Cemented Total Knee Arthroplasties Have Similar Outcomes but Cementless Patellar Component Migration was Observed in a Paired Randomized Control Trial

BackgroundCementless total knee arthroplasty (TKA) has become increasingly popular. Some surgeons are concerned about pain, implant stability, and metal-backed patellar component survivorship. This study investigated the outcomes of cementless compared with cemented TKA in bilateral cases. MethodsWe randomized 80 knees in 40 osteoarthritic knee patients who underwent bilateral TKA with patellar resurfacing under one anesthesia. All participants received cementless prostheses in one knee and cemented prostheses in the other. The outcomes were knee function measured by the forgotten joint scores, modified Western Ontario and McMaster Universities Osteoarthritis Index, knee ranges of motion, pain levels, operative times, radiographic outcomes, and complications. All knees were followed for a minimum of 2 years (2 to 3 years). ResultsCementless and cemented TKA had similar functional outcomes in forgotten joint score (97 ± 5 versus 98 ± 3 points, P = .52), modified Western Ontario and McMaster Universities Osteoarthritis Index score (3 ± 4 versus 3 ± 2 points, P = .96), and ranges of motion (134 ± 7° versus 134 ± 7°, P = .16). The postoperative pain was also similar (P > .05). There were 4 cementless patellar components had superior migration for an average of 3.5 mm (range, 1.77 to 4.16) without loosening. The mean time of migration was 4 (range, 2 to 6) weeks. ConclusionsCementless TKA had similar functional outcomes and recovery patterns compared with cemented TKA. However, there was concern of cementless component migration at patellae.

Excellent 20-Year Results of Total Hip Arthroplasty With Highly Cross-Linked Polyethylene on Cobalt-Chromium Femoral Heads in Patients ≤50 Years

BackgroundHighly cross-linked polyethylene (HXLPE) acetabular bearing surfaces have appeared to offer excellent wear resistance, low incidence of wear-related osteolysis, and high implant survivorship at 10-year to 15-year follow-up. However, concerns over potential performance deterioration at longer-term follow-up remain — particularly in younger patients — and outcome data into the third decade have not been available. MethodsWe retrospectively assessed 62 patients (68 hips) who underwent primary total hip arthroplasty (THA) at age ≤50 years with a single manufacturer’s cementless components, remelted HXLPE liner, and small diameter (26 and 28 millimeter) cobalt-chromium (CoCr) femoral heads at minimum 18-year follow-up. We assessed clinical outcomes (modified Harris Hip score, University of California Los Angeles Activity Score, polyethylene wear rates, radiographic findings (osteolysis, component loosening), and implant survivorship. ResultsAt 20.6-year mean follow-up (range, 18 to 23 years) modified Harris Hip scores for surviving hips remained an average of 41 points above preoperative baseline (49 versus 90, P < .001) and UCLA scores 2.8 points above baseline (3.7 versus 6.4, P < .001). Wear analysis revealed a population linear wear rate of 0.0142 mm/y (standard deviation (SD), 0.0471) and volumetric wear rate of 10.14 mm3/y (SD, 23.41). Acetabular lysis was noted in 2 asymptomatic hips at 16.6 and 18.4 years. No components were radiographically loose. Survivorship free from wear-related revision was 100% at 20 years (97% free from any revision). ConclusionThe HXLPE-CoCr bearing couple with small femoral heads continues to be extremely effective 20 years after primary THA in the younger patient population.

Cemented total knee arthroplasty provides greater knee range of motion at 2years than cementless technique.

Optimal fixation method between cemented, cementless, and hybrid techniques for total knee arthroplasty (TKA) is still debated. The purpose of this study is to evaluate the clinical outcomes of patients undergoing cemented versus cementless TKA. We reviewed 168 patients who underwent a primary TKA at a single academic institution between January 2015 and June 2017. Patients were categorized into cemented (n = 80) or cementless (n = 88) groups. Only patients with greater than or equal to 2-year follow-up were included in the study. Multivariate regressions were performed to analyze the relationship between the surgical fixation technique and the clinical outcomes. There were no differences in demographics or baseline operative characteristics between the two groups. The cemented group had fewer manipulations under anesthesia (MUA) (4 vs. 15, p = 0.01), longer intraoperative tourniquet times (101.30 vs. 93.55min, p = 0.02), and increased knee range of motion (ROM) at final follow-up (111.48 vs. 103.75°, p = 0.02) compared to the cementless group. Both cemented and cementless component fixation are viable options for (TKA). This study found that patients who underwent a cemented TKA required fewer MUA's and had greater final ROM compared to patients undergoing cementless TKA. Additional research is required regarding cementless and cemented fixation. We believe that the choice of which fixation technique to use ultimately comes down to patient characteristics and surgeon preference.

The Knee-Fix study: study protocol for a randomised controlled trial evaluating cemented and cementless components in total knee arthroplasty

BackgroundTotal knee arthroplasty (TKA) is an effective procedure for patients with a variety of knee conditions. The main cause of aseptic TKA failure is implant loosening, which has been linked to poor cement mantle quality. Cementless components were introduced to offer better longer-term biological fixation through osseointegration; however, early designs led to increased rate of revision due to a lack of initial press-fit and bony ingrowth. Newer highly porous metal designs may alleviate this issue but randomised data of fully uncemented TKA (tibial, femoral, patella) is lacking. The aim of the Knee-Fix study is to investigate the long-term implant survival and patient outcomes of fully uncemented compared with cemented fixation in TKA. Our study hypothesis was that uncemented TKA would be as clinically reliable and durable as the gold-standard cemented TKA.MethodsThe Knee-Fix study is a two-arm, single-blinded, non-inferiority randomised controlled trial with 160 patients in each arm and follow-up at 6 weeks, 6 months, 12 months, 24 months, 5 years and 10 years. The primary outcome of interest is implant fixation, which will be measured by assessment of postoperative progressive radiolucencies with the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Secondary outcome measures are patient-reported outcomes, measured using Oxford Knee Score (OKS), International Knee Society System (IKSS), Forgotten Joint Score-12 (FJS-12), EuroQol (EQ-5D-5L), VAS Pain, Patient Satisfaction Score and Net Promoter Score.DiscussionWhile cemented fixation remains the gold standard, a growing proportion of TKA are now implanted cementless. Highly porous metal cementless components for TKA can offer several benefits including potentially improved biological fixation; however, long-term outcomes need further investigation. This prospective study will help discern long-term differences between the two techniques.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12616001624471. Registered trial name: Knee-Fix study (Cemented vs Uncemented Total Knee Replacement). Registered on 24 November 2016.

Anterior total hip arthroplasty outcomes in the treatment of femoral neck fractures: a retrospective cohort study

Background: A prior study reported a 22% complication rate using the direct anterior (DA) approach for total hip arthroplasty (THA) in the displaced femoral neck fracture population. This seemed contrary to institutional experience; this study investigated outcomes and complication rates for DA THA used in the displaced femoral neck fracture population. Methods: This retrospective cohort study identified and analyzed patients undergoing DA THA for a femoral neck fracture over a 4-year period at a level 1 academic trauma center who were treated by an experienced senior surgeon. Results: Thirty-seven patients (21 women, 16 men) were included in the final analysis. The mean age was 70.9 (SD 11.30) years. All patients received cementless components. One (2.7%) intraoperative greater trochanteric fracture and one (2.7%) in-hospital mortality were recorded. Average follow-up was 10.46 mo (range 0 to 53 mo). There were no reported postoperative periprosthetic fractures, dislocations, or revision arthroplasties. No deep venous thromboses or pulmonary embolisms occurred within 90 days of surgery. There were two (5%) deep infections. The overall complication rate was 8.1%. Patient-reported outcomes were available for 32 patients. Visual Analog Scale pain was 2.59 at 6 wk average compared with 1.83 at 12 mo. Hip Disability and Osteoarthritis Outcome Score Quality of Life at 6 wk averaged 46.69 compared with 59.24 at 12 mo. Conclusions: The direct anterior approach for THA can be a safe option for experienced surgeons. Level of Evidence: Level III.

Femoral Stem Cementation in Primary Total Hip Arthroplasty.

Femoral stem cementation has undergone considerable investigation since bone cement was first used in arthroplasty, leading to the evolution of modern femoral stem cementation techniques. Although there is a worldwide trend toward the use of cementless components, cemented femoral stems have shown superiority in some studies and have clear indications in specific populations. There is a large evidence base regarding cement properties, preparation, and application techniques that underlie current beliefs and practice, but considerable controversy still exists. Although the cementing process adds technical complexity to total hip arthroplasty, growing evidence supports its use in certain cohorts. As such, it is critical that orthopaedic surgeons and investigators have a thorough understanding of the fundamentals and evidence underlying modern cementation techniques.

Anatomic acetabular reconstruction with femoral head autograft for developmental dysplasia of the hip (DDH) with a minimum follow-up of 10 years.

DDH with coxarthrosis causes significant deformity and bone deficiency. Various reconstructive techniques have been proposed to treat developmental dysplasia of the hip. However, the existing literature has not yet reached a consensus on the best technique regarding long-term survival. This study aims to evaluate the long-term survival of uncemented hydroxyapatite (HA) coated acetabular components augmented with a femoral head autograft. We retrospectively reviewed the cases of 31 hips in 29 patients (24 female, 5 male, mean age 45.06 years) treated with HA-coated cementless components and femoral head autograft between 2000-2008 with a minimum follow-up of 10 years. Graft resorption, cup loosening and the anatomical hip centre were determined. Functional outcomes were calculated using the Harris Hip Scoring system. The survival of the acetabular component was evaluated using the Kaplan-Meier method. In 24 hips (77,4%), we reconstructed the hip centre anatomically. The remaining cups had variable deviations from the anatomical rotation centre. Only one patient required revision due to loosening. Survival analysis revealed 96.8% survival at 10 years. The mean Harris Hip Score was 39.23 preoperatively and 84.77 at final follow-up. There was no statistical correlation between revision and any of the measured parameters. Acetabular reconstruction with a femoral head autograft allows for anatomical cup positioning, early structural support and increases bone stock for future revisions. Although our prior cemented cup study showed that anatomical cup orientation is critical, this study demonstrated the absence of a correlation between implant failure and cup positioning, suggesting that HA-coated cementless cups are more stable and forgiving. HA-coated acetabular cups augmented with femoral head autograft provided long-term, reliable and durable cup fixation in dysplastic hips of young adults.

Component migration, bone mineral density changes, and bone turnover markers in cementless and cemented total knee arthroplasty: a prospective randomized RSA study in 53 patients with 2-year follow-up.

Cementless tibial components migrate initially until osseointegration and preserve periprosthetic bone. Cemented tibial components are fixed from surgery but loose periprosthetic bone. Little is known about bone formation and resorption biomarkers in relation to component fixation and bone mineral density (BMD) changes of cementless and cemented total knee arthroplasty. We hypothesize a similar migration of cemented and cementless tibial components between 1- and 2-year follow-up indicating a stable long-term fixation. In a prospective patient-blinded randomized study, we compared cementless (n = 27) and cemented (n = 26) tibial components with radiostereometry measured migration (MTPM = Maximum Total Point Motion: point of component that migrates the most) and changes in BMD and biochemical bone turnover markers (BTMs) until 24months after surgery. The mean MTPM between 12 and 24months were similar between groups with -0.06mm (95% CI -0.23; 0.11) in the cementless group compared to 0.02mm (95% CI -0.07; 0.11) in the cemented group. However, there was a higher proportion of cementless components (16/25) than cemented components (7/24) with continuous migration (MTPM > 0.2mm) (p = 0.02). In the medial and anterior region below the tibial components, the BMD increased by mean 1.8% and 7.4% for cementless components and decreased by mean 8.6% and 4.2% for cemented components until 24-month follow-up. In both groups, BTMs initially showed increased bone resorption (CTx) and bone formation (P1NP) followed by normalization to pre-operative levels at 6months post-surgery. More cementless components than cemented components showed continues migration which suggest a higher risk of early revision. Bone turnover increased post-surgery in both groups, but did not explain the difference in change in periprosthetic BMD. I.

Assessment of in vivo bone activity patterns in medial mobile-bearing unicompartmental knee arthroplasty : a prospective SPECT/CT study.

Higher osteoblastic bone activity is expected in aseptic loosening and painful unicompartmental knee arthroplasty (UKA). However, insights into normal bone activity patterns after medial UKAs are lacking. The aim of this study was to identify the evolution in bone activity pattern in well-functioning medial mobile-bearing UKAs. In total, 34 patients (13 female, 21 male; mean age 62 years (41 to 79); BMI 29.7 kg/m2 (23.6 to 42.1)) with 38 medial Oxford partial UKAs (20 left, 18 right; 19 cementless, 14 cemented, and five hybrid) were prospectively followed with sequential 99mTc-hydroxymethane diphosphonate single photon emission CT (SPECT)/CT preoperatively, and at one and two years postoperatively. Changes in mean osteoblastic activity were investigated using a tracer localization scheme with volumes of interest (VOIs), reported by normalized mean tracer values. A SPECT/CT registration platform additionally explored cortical tracer evolution in zones of interest identified by previous experimental research. Significant reduction of tracer activity from the preoperative situation was found in femoral and anteromedial tibial VOIs adjacent to the UKA components. Temporarily increased osteoblastic bone activity was observed in VOIs comprising the UKA keel structure at one year postoperatively compared to the preoperative activity. Persistent higher tracer uptake was found in the posterior tibial cortex at final follow-up. Multivariate analysis showed no statistical difference in osteoblastic bone activity underneath cemented or cementless components. Well-functioning medial mobile-bearing UKAs showed distinct changes in patterns of normalized bone tracer activity in the different VOIs adjacent to the prosthetic components, regardless of their type of fixation. Compared to the preoperative situation, persistent high bone activity was found underneath the keel and the posterior tibial cortex at final follow-up, with significant reduced activity only being identified in femoral and anteromedial tibial VOIs. Cite this article: Bone Joint J2022;104-B(1):34-44.

Prospective Three-Year Outcomes Comparing Cemented and Cementless Fixation in the Trabecular Metal Total Ankle Arthroplasty

Category:Ankle; Ankle ArthritisIntroduction/Purpose:In total ankle arthroplasty (TAA), the implant can be inserted with or without cement. The United States Food and Drug Administration (FDA) requires cement fixation on most TAAs, whereas cementless TAA can be performed in other countries. The laterally placed trabecular metal ankle replacement is inserted using a jig and a fibular osteotomy. The tibia and talus are reamed to match the curved contour of the replacement. Two rails on the tibial and talar component are used to transfix the cementless component onto bone. FDA licensing requires a bead of cement applied on the fixation rails to assist in early component fixation. The purpose of this study was to compare early and three-year results of TAA with and without rail cement performed in six countries.Methods:One hundred and twenty-one patients were prospectively enrolled (from 2014 to 2016) across 11 centers in six countries. Patients were assigned cement or no cement based on the surgeon's practice. EQ5D, AOS, and AOFAS scores were obtained preoperatively, six weeks and six months postoperatively, and yearly thereafter. Secondary endpoints were revision of metal components for infection or loosening. Statistical significance was tested by the Wilcoxon Signed Rank Test and set at p=0.05.Sixty ankles had cement; 61 ankles were press fit. Cement augmentation patients were heavier and older. Cement cases had longer surgical times (173 minutes, 95% CI 162.8 to 183.2, versus 150 minutes, 95% CI 139.9 to 158.4). The sites using cement fixation varied. Of 121 cases, 117 were followed at one year, 96 at two years, and 84 at three years. Three patients underwent revision and five withdrew (one died, two lost to follow-up, and two requested discontinuation).Results:The EQ5D scores demonstrated better outcomes for the press fit component without cement at six weeks (p<0.001), six months (p=0.001), one year (p=0.005), and two years (p=0.02), but not at three years (p=0.132). The AOS Disability scale demonstrated better outcomes for the press fit component at six weeks (p=0.008), six months (p=0.022), one year (p=0.020) and two years (p=0.024). The AOS Pain scale demonstrated better outcomes for the press fit component at six months (p=0.05). The AOFAS score demonstrated better outcomes for the press fit component at six weeks (p<0.001), but no significant differences thereafter. Survivorship for joint replacement (revision of metal components) was 97.4% for the full cohort. Three metal components were revised in three ankles in the cementless group (chi square not significant).Conclusion:Patient-reported outcome measures favored cementless, press fit fixation through two years postoperatively, with outcomes equalizing between the groups at three years postoperatively. Given the better early outcomes with the press fit design, there does not seem to be a need to augment fixation with cement in this total ankle implant design. There were two metal component revisions and one revision associated with loosening in the cementless group. The significant demographic differences between the groups indicate that a randomized clinical trial is needed to comprehensively define differences in early outcomes and to evaluate long-term results.

THA in patients with neglected acetabular fractures.

Introduction: Total hip arthroplasty (THA) outcomes in patients with neglected acetabular fractures are less favourable compared to THA for osteoarthritis or inflammatory arthritis. These poorer clinical outcomes are largely due to an unexpected bone deficiency, and the procedure is more time-consuming and complicated for cases that require acetabular reconstruction and bone grafting. The clinical outcomes of THA in neglected acetabular fractures are not often studied. Methods: This study is a retrospective single surgeon series of THA for 51 neglected acetabular fractures in 49 patients treated with THA alone, open reduction and internal fixation with THA, or acetabular defect reconstruction THA. Our series aims to focus on the surgical technique and describe the functional and radiological outcomes of neglected acetabular fractures treated with different THA approaches by a single surgeon. Results: Using the Harris Hip score at the mean long-term follow-up, there was a clear improvement in 90% of patients in the present study. The long-term results are encouraging in terms of clinical improvement, radiographic restoration of acetabular bone stock, and the centre of restoration. Discussion: The series shows that with proper planning and reconstruction using structural bone grafting techniques, a neglected fracture-dislocation with loss of structural support can be satisfactorily treated using primary components alone. Bony reconstruction and use of primary cementless components ensure long-term survival and preserve bone stock for an easier revision of THA, if necessary, in the future.

To Cement or Not to Cement: Have We Answered the Question?: Commentary on an article by Hasan R. Mohammad, MBChB, MRes(Dist), MRCS (Eng), DPhil(Oxon), et al.: "A Matched Comparison of the Long-Term Outcomes of Cemented and Cementless Total Knee Replacements, Based on Data from National Databases. An Analysis from the National Joint Registry of England, Wales, Northern Ireland and the

Commentary The debate regarding the optimal method of fixation in total knee arthroplasty (TKA) has continued for almost 40 years, beginning with case series and culminating recently with intermediate-term results from randomized controlled trials (RCTs). The ongoing interest in this debate is justified: TKA patients are getting younger, making implant longevity a priority; post-TKA dissatisfaction remains prevalent, leading to the question of whether implant fixation contributes to pain; and infection is still the most common reason for revision, prompting the desire to simplify surgery and reduce operative time. The popularity of cementless TKA has very recently increased, as reflected in the 2020 annual reports of the Australian Orthopaedic Association National Joint Replacement Registry and the American Joint Replacement Registry. Yet, to date, there have been few long-term (>10-year) large-scale studies that have investigated the clinical outcomes of cemented versus cementless TKA, while accounting for pertinent variables such as age, body mass index, and bone quality. Mohammad and colleagues have challenged this gap in the literature by conducting a rigorous propensity-score-matched cohort analysis of 22,477 patients treated with cementless TKA and 22,477 patients treated with cemented TKA from 2004 to 2018 with Great Britain’s National Joint Registry (NJR). This is the largest long-term matched analysis of TKA outcomes according to fixation type. Their results can be interpreted differently, depending on where your personal loyalties lie. Cement advocates will point out the lower overall implant survival rate, higher rate of reoperation (but not of component revision), and higher rate of revision for pain associated with cementless TKA. Cement cynics will stress the lower infection rate, lower overall reoperation rate, and lower aseptic loosening rate in patients <65 years of age associated with cementless TKA. Regardless of these differences, the study found that both fixation techniques exhibited a survival probability of >95%. Furthermore, historical concerns associated with cementless fixation, including early loosening and periprosthetic fractures, were not observed, nor were older designs associated with higher failure rates. Are the above results enough to encourage the masses to abandon cement in primary TKA? In isolation, probably not. However, the mounting evidence creates a compelling argument. Over the last 10 years, 6 separate RCTs comparing fixation techniques have found little difference in revision rates or survival1-6, at least in the short term. Does the internal consistency of each of these trials apply to your clinical practice? Not universally, but for a young patient who presents with good bone quality, mild/moderate deformity, and no predictors of poor postoperative pain coping, what strong argument exists against attempting cementless TKA? One may be able to point to the observation that cementless components tend to migrate more in the first 3 months to 2 years, but cemented components do so as well, sometimes even to a greater extent7. It is true that several important questions remain: what happens to the current RCT data at intermediate and long-term milestones? Are implant revisions easier with one type of fixation versus the other? Does fixation survival differ in mechanically versus kinematically aligned TKA? Is there an optimal porous surface coverage and keel/stem length that stands above other designs? Evidently, it will take more high-quality studies to answer all of these questions, but that should not necessarily stop surgeons from being selective in their clinical decisions. For now, it is clear that cement is certainly here to stay in primary TKA, especially in older, osteoporotic patients. However, we appear to be headed to what has already happened in hip arthroplasty—a recognition that a one-method-fits-all approach does not work for every patient. I congratulate the authors in helping us get one step closer to this reality.

Cementless Highly Porous Titanium Tibial Base Plate in Total Knee Arthroplasty – Midterm Outcomes.

Introduction &amp; Aims&#x0D; TKA in more active and young patients has prompted the interest in more durable and biological methods of Osteo-integration with cementless components. With the emergence of improved biomaterials like porous titanium and the success, search for a cementless TKA with long-term durability and survivorship may have ended. This is a retrospective study of 492 consecutive TKAs using Cementless tibial fixation, reporting on the early 4 years clinical and radiological outcomes.&#x0D; Method&#x0D; We studied 492 TKAs performed consecutively by a single surgeon between 1stJan. 2010 and 31stDec. 2015 using a cementless, fixed bearing tibial tray (porous–Regenerex, Vanguard, Zimmer-Biomet) and a cementless femoral component (Vanguard) with no exclusion criteria. Clinical and radiological follow-up was done on these patients and in addition a comprehensive joint registry review was performed on the whole cohort (Level II evidence).&#x0D; Results&#x0D; The average Knee Society Score at final follow-up was 89.33, average pre-op being 42.06. Average post-op WOMAC score was 43.45 and average pre-op was 77.78. On radiological examination, no patients had osteolysis around tibial base plate. In our series 9 patients were revised, out of which only 4 patients had the tibial tray and femoral component revised and 5 patients had patella resurfacing or liner exchange. Overall survivorship of the cementless tibial component is excellent with a survivorship of 99.4% at 5.9 years based on a comprehensive AOANJRR data.&#x0D; Conclusions&#x0D; Cementless tibial fixation using a porous titanium construct can provide stable bone ingrowth fixation on the tibial side with excellent and predictable early 4 to 5 year clinical and radiological outcomes.

Five-year results of a randomised controlled trial comparing cemented and cementless Oxford unicompartmental knee replacement using radiostereometric analysis

BackgroundCementless fixation is an alternative to cemented unicompartmental knee replacement (UKR). The aim of this study was to determine if cementless UKR fixation is as good as cemented by comparing the five-year migration measured radiostereometric analysis (RSA) in a randomised controlled trial. MethodsThirty-nine patients were randomised to receive either a cemented or a cementless Oxford UKR and were studied at intervals up to five years to assess migration with RSA and radiolucencies with radiographs. ResultsDuring the first year there was a small and significant amount of migration, predominantly in an anterior direction, of both the cemented (0.24 mm, SD 0.32, p = 0.01) and cementless (0.26 mm, SD 0.31, p = 0.00) femoral components. Thereafter there was no significant migration in any direction. At no stage was there any significant difference between the migrations of the cemented or cementless femoral components. During the first year, particularly the first three months, the cementless tibial components subsided 0.28 mm (SD 0.19, p = 0.00). This was significantly (p = 0.00) greater than the subsidence of the cemented tibial component (0.09, SD 0.19, p = 0.28). Between the second and fifth years there was no significant migration of either cemented or cementless tibial components.At five years radiolucent lines occurred significantly less with cementless (one partial) compared to cemented (six partial and one complete) tibial components. ConclusionsAs, between two and five years, there was no significant migration of cemented or cementless components, and no significant difference between them, we conclude that cementless fixation is as reliable as cemented. It may be better as there are fewer radiolucent lines.

Low-dose vancomycin-loaded cement spacer for two-stage revision of infected total hip arthroplasty.

Objectives This study aims to evaluate the success rate in terms of eradication of infection and long-term outcomes of two- stage revision arthroplasty with spacers loaded with low-dose vancomycin alone for the treatment of an infected hip arthroplasty.Patients and methods The records of 42 two-stage exchange arthroplasty patients (16 males, 26 females; mean age 61 years; range, 30 to 80 years) treated between January 1999 and January 2009 were included in this retrospective study. In the first stage, following removal of the prosthesis and debridement, a spacer consisting of 1 g of vancomycin per 40 g of cement was placed in the infected joint space. Patients received six weeks of intravenous antibiotics according to intraoperative cultures. After cessation of systemic antibiotic treatment, with normal C-reactive protein and erythrocyte sedimentation rate levels, second stage surgery with cementless components was performed.Results The mean follow-up duration was seven (range, 3 to 13) years. Two patients (4.7%) developed re-infection after two-stage reimplantation and one patient underwent a resection arthroplasty after repeated debridements. Five years of survival was 92.9% with Kaplan-Meier survival analysis.ConclusionFor chronic infected total hip revisions, two-stage revision arthroplasty with low-dose vancomycin impregnated cement spacers have comparable re-infection and success rates. Low-dose vancomycin promotes effective infection control and reduces antibiotic toxicity.

Explantation, Followed by Serial Debridement Without Antibiotic Spacers and Subsequent Revision With Cementless Components, Is Associated With High Remission Rates and Low Mortality in Periprosthetic Hip Joint Infections

BackgroundIn difficult-to-treat cases, it is necessary to add debridement steps in prosthesis-free interval of 2-stage exchange. We aimed to analyze the functional and clinical outcome of patients treated with a multistage exchange of total hip arthroplasty without the use of spacers, rather only cementless implants. MethodsBetween 2009 and 2018, 84 patients (mean age: 67.3 [39-90] years) suffering chronic late-onset periprosthetic joint infection (PJI) were treated using a multistage prosthesis exchange without spacers. The mean follow-up was 70 ± 45.3 [14-210] months. The treatment included prosthesis exchange and at least 1 additional revision step before a reimplantation, owing to ongoing acute infection in the prosthesis-free interval. High-efficiency antimicrobial therapy was administered in between, which was discontinued after cementless revision implantation. ResultsThe mean number of revisions between explantation and implantation was 2.6 (1-9). The most common microorganism was Staphylococcus epidermidis (53.6%) followed by Staphylococcus aureus (16.7%) and Cutibacterium acnes (11.9%). The bacterial load was more than one bacterium per patient in 38% of cases. All patients could be treated using a cementless implant. PJI remission was achieved in 92% of cases. Overall, 9 prostheses (11%) were replaced because of an ongoing PJI or fracture. The mean modified Harrison Hip Score was 63.4 (22-88) points. No patient died. ConclusionMultistage total hip arthroplasty exchange showed high remission rates and low mortality in difficult-to-treat cases. Spacer-free and multistage treatment had no negative effect on the success rate or functional outcome, consistent with the results of published 2-stage exchange studies. Implantation of an uncemented press-fit prosthesis was possible in all patients with no elevated periprosthetic fracture rate.