Fixation In Total Knee Arthroplasty Research Articles

Tantalum Cementless Versus Cemented Total Knee Arthroplasty: A Meta-analysis of Level 1 Studies

Controversy exists on the ideal type of fixation in total knee arthroplasty (TKA). Noncemented fixation has been theorized to improve patient outcomes and longevity of implantation without increased risk of aseptic loosening or radiolucent lines. We sought to compare (1) patient-reported outcomes, (2) survivorship, and (3) revision rates for all-cause and aseptic loosening in a noncemented tantalum total knee with its cemented counterpart. Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were searched using a combination of keywords "trabecular metal," "tantalum knee," "total knee arthroplasty," and "cementless trabecular." Patient demographics such as age, sex, and body mass index were collected. Outcomes such as Knee Society Scores (KSSs), revisions, and radiolucent lines were recorded for analysis. Four randomized controlled trials involving 507 patients with an average 5-year follow-up were eligible for meta-analysis. No differences were observed in any demographics such as age, sex, body mass index, nor preoperative KSS. Patients in the cemented cohort improved from preoperative KSS 46.4 to postoperative KSS 90.4 while the tantalum cohort improved from 46.4 to 89.3. No statistical difference was observed in postoperative KSS mean difference between groups. Six patients from the tantalum group underwent revision with one patient for aseptic loosening. Twelve patients from the cemented group underwent revision with four patients for aseptic loosening. No statistical difference was observed between rates of revision, aseptic loosening, or radiolucent line development. Patient-reported outcomes improved postoperatively in both groups. No differences were detected between the cemented and noncemented TKAs in patient-reported outcomes, revision rates, or radiolucent line development. Noncemented tantalum fixation seems equivalent to cemented TKA survivorship. Longer term follow-up of these randomized controlled trials may provide a clearer understanding whether a difference exists.

Uncemented Tibial Fixation Has Comparable Prognostic Outcomes and Safety Versus Cemented Fixation in Cruciate-Retaining Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

Cemented and uncemented fixation are the primary methods of tibial prosthesis fixation in total knee arthroplasty. However, the optimal fixation method remains controversial. This article explored whether uncemented tibial fixation has better clinical and radiological outcomes, fewer complications, and revision rates compared to cemented tibial fixation. We searched the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2022 to identify randomized controlled trials (RCTs) that compared uncemented total knee arthroplasty (TKA) and cemented TKA. The outcome assessment consisted of clinical and radiological outcomes, complications (aseptic loosening, infection, and thrombosis), and revision rate. Subgroup analysis was used to explore the effects of different fixation methods on knee scores in younger patients. Nine RCTs were finally analyzed with 686 uncemented knees and 678 cemented knees. The mean follow-up time was 12.6 years. The pooled data revealed significant advantages of uncemented fixations over cemented fixations in terms of the Knee Society Knee Score (KSKS) (p = 0.01) and the Knee Society Score-Pain (KSS-Pain) (p = 0.02). Cemented fixations showed significant advantages in maximum total point motion (MTPM) (p < 0.0001). There was no significant difference between uncemented fixation and cemented fixation regarding functional outcomes, range of motion, complications, and revision rates. When comparing among young people (<65 years), the differences in KSKS became statistically insignificant. No significant difference was shown in aseptic loosening and the revision rate among young patients. The current evidence shows better knee score, less pain, comparable complications and revision rates for uncemented tibial prosthesis fixation, compared to cemented, in cruciate-retaining total knee arthroplasty.

Cementless Total Knee Arthroplasty Over the Past Decade: Excellent Survivorship in Contemporary Designs

BackgroundCementless fixation in total knee arthroplasty (TKA) is re-emerging due to improvements in biomaterials, surgical technique, and implant design. Albeit rare, failure of osseointegration typically occurs within the first 2 years, and limited data exist on survivorship of the modern cementless TKA designs. This study evaluated clinical survivorship of 2 contemporary cementless TKA designs at minimum 2-year follow-up. MethodsA total of 627 cementless TKAs were performed up to July 2022. Three hundred thirty-nine cases were eligible for 2-year follow-up. Indications centered around bone quality and involved predominantly younger patients. The 2 designs consisted of tibial components with a highly porous titanium ingrowth surface, a central keel, and peripheral cruciform pegs with a porous cobalt-chromium femur. Survivorship estimates were calculated using right-censored non-parametric Kaplan–Meier methodologies. A total of 226 TKAs obtained minimum 2-year follow-up with a mean of 3.6 years (range, 2 to 10). ResultsThe all-cause revision rate was 2.4% (8 of 339). The revision rate due to aseptic loosening was 0.6% (2 of 339) consisting of 2 femoral components. No tibial components were revised for aseptic loosening. Kaplan–Meier survivorship free from aseptic loosening was 99% (95% confidence interval 98 to 100) at a maximum of 10 years. ConclusionThese results demonstrate encouraging survivorship of cementless fixation in primary TKA with use of contemporary ingrowth biomaterials and modern implant designs. This particular tibial implant design with a highly porous titanium fixation surface, central keel, and peripheral cruciform pegs demonstrated excellent clinical survivorship without failure which may portend superior fixation. Level of EvidenceIV–case series, no control group/historical control group.

Treatment of severe medial tibial bone defect in primary total knee arthroplasty with autogenous bone graft and plate fixation

To explore the technique of autogenous bone graft combined with plate fixation in total knee arthroplasty(TKA) with severe proximal medial tibial bone defect. From March 2012 to October 2018, 21 patients (9 males and 12 females) with severe bone defects in the proximal medial tibia during primary total knee arthroplasty were treated with autogenous structural bone grafting and steel plate fixation, with an age of 61 to 77 years old with an average of (69.6±9.1) years and a course of 64 to 257 months with an average of (73.6±170.7) months. According to Rand classification, there were 13 cases of type Ⅲb and 8 cases of type Ⅳb. Postoperative complications were observed, and knee joint function was evaluated by the Hospital for Special Surgery (HSS) score and SF-36 quality of life score. All 21 patients were followed up for 37 to 64 months with an average of (49.5±13.7) months. The incisions of all patients healed smoothly, and 2 patients developed lower limb intermuscular venous plexus thrombosis after operation. There were no periprosthetic infection, loosening of prosthesis and other complications. The autogenous bone grafts of all patients achieved bony healing during postoperative X-ray follow-up, and the healing time was 8 to 13 months with an average of (10.1±2.3) months. The HSS score of patients increased significantly from 30 to 48 with an average of (53.4±4.2) before operation to 75 to 92 with an average of (81.2±8.4) at the final follow-up (P<0.05). The SF-36 quality of life score of patients after operation was significantly different from that before operation (P<0.05). The technique of autogenous bone graft combined with steel plate fixation can achieve satisfactory osseointegration effect in the treatment of severe proximal tibial bone defects in primary knee arthroplasty, with less complications and obvious improvement in knee function.

The mid-term survival of cemented, uncemented, and hybrid fixation of the ACS mobile bearing total knee arthroplasty.

Till today, Cemented Fixation in Total Knee Arthroplasty (TKA) is significantly more used than Hybrid or Uncemented Fixation. The purpose of this study was to compare Cemented, Uncemented and Hybrid Fixation of the ACS Mobile Bearing TKA at Mid-term follow-up. This study was an extended data report of our prospective single-center, single-blinded randomized controlled clinical trial comprising 105 patients. The primary outcome was survival at five years of follow-up calculated by Kaplan-Meier and Log-rank test. The secondary outcome was function based on patient-reported outcome measures (PROMs). Eighty-three patients were included, of which 25 belonged into group A (Cemented), 28 in group B (Uncemented), and 30 in group C (Hybrid). Mean follow-up was 5.8 ± 0.7 (range 5-7) years. The 5-year survival rates were 96.8% (95%CI: 90.5; 100) in the Cemented group, 94.2% (95%CI: 86.4; 100) in the Uncemented group, and 93.8% (95%CI: 85.4; 100) in the Hybrid group for revision for any reason (p = 0.80). Functional outcome was similar among the groups. In our cohort of ACS Mobile Bearing TKA, there was no difference between Cemented, Uncemented, and Hybrid Fixation with regard to survival and function at Mid-term follow-up. Dutch Trial Register (NTR3893), 2013-03-12. II.

Clinical Results in Posterior-Stabilized Total Knee Arthroplasty with Cementless Tibial Component in Porous Tantalum: Comparison between Monoblock and Two Pegs vs. Modular and Three Pegs

Nowadays, total knee arthroplasty (TKA) is widely considered to be the gold standard for treatment of end-stage knee osteoarthritis. Although the optimal mode of fixation in TKA continues to be an important area of investigation, cementless fixation offers the possibility to gain biologic fixation, preserve bone stock and mineral density, and potentially improve survivorship. The purpose of this retrospective study was to evaluate the clinical results of a posterior-stabilized total knee arthroplasty with cementless tibial component in porous tantalum, comparing two groups: Group A (30 patients), TKA with a monoblock component and two pegs, and Group B (22 patients), with a modular component and three pegs. Knee Society Score (KSS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were submitted to the patients, and radiographs were collected at the last follow-up. The mean follow-up was 26.32 (20–40) months. Significant differences were not detected between the postoperative KSS values in the two groups (p = 0.44). Evaluating KOOS outcomes, we found in Group A that the rating system showed a statistically significant improvement from a preoperative average rating of 51.4 (SD ± 15) to an average of 72.66 (SD ± 19) at final follow-up (p &lt; 0.05). In Group B, the KOOS rating system showed a statistically significant improvement from a preoperative average rating of 48.3 (SD ± 18) to an average of 79.54 (SD ± 17) postoperatively (p &lt; 0.05). Comparing KOOS final outcomes between groups, we found no statistically significant difference at the mean final follow-up (p = 0.20), with the exception of the sport-related section (p &lt; 0.05). Radiological evaluation at the final follow-up did not show any sign of polyethylene wear, radiolucency, septic or aseptic loosening, or change in alignment in either group. The current study demonstrates an excellent survivorship of cementless tibial components in porous tantalum and the possibility of osseous integration, without significant differences between the two groups under investigation.

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.

Similar Healthcare Utilization and 1-Year Patient-Reported Outcomes between Cemented and Cementless Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

Cementless fixation for total knee arthroplasty (TKA) has gained traction with the advent of newer fixation technologies. This study assessed (1) healthcare utilization (length of stay (LOS), nonhome discharge, 90-day readmission, and 1-year reoperation); (2) 1-year mortality; and (3) 1-year joint-specific and global health-related patient-reported outcome measures (PROMs) among patients who received cementless versus cemented TKA. Patients who underwent cementless and cemented TKA at a single institution (July 2015-August 2018) were prospectively enrolled. A total of 424 cementless and 5,274 cemented TKAs were included. The cementless cohort was propensity score-matched to a group cemented TKAs (1:3-cementless: n = 424; cemented: n = 1,272). Within the matched cohorts, 76.9% (n = 326) cementless and 75.9% (n = 966) cementless TKAs completed 1-year PROMs. Healthcare utilization measures, mortality and the median 1-year change in knee injury and osteoarthritis outcome score (KOOS)-pain, KOOS-physical function short form (PS), KOOS-knee related quality of life (KRQOL), Veteran Rand (VR)-12 mental composite (MCS), and physical composite (PCS) scores were compared. The minimal clinically important difference (MCID) for PROMs was calculated. Cementless TKA exhibited similar rates of median LOS (p = 0.109), nonhome discharge disposition (p = 0.056), all-cause 90-day readmission (p = 0.226), 1-year reoperation (p = 0.597), and 1-year mortality (p = 0.861) when compared with cemented TKA. There was no significant difference in the median 1-year improvement in KOOS-pain (p = 0.370), KOOS-PS (p = 0.417), KOOS-KRQOL (p = 0.101), VR-12-PCS (p = 0.269), and VR-12-MCS (p = 0.191) between the cementless and cemented TKA cohorts. Rates of attaining MCID were similar in both cohorts for assessed PROMs (p > 0.05, each) except KOOS-KRQOL (cementless: n = 313 (96.0%) vs. cemented: n = 895 [92.7%]; p = 0.036). Cementless TKA provides similar healthcare-utilization, mortality, and 1-year PROM improvement versus cemented TKA. Cementless fixation in TKA may provide value through higher MCID improvement in quality of life. Future episode-of-care cost-analyses and longer-term survivorship investigations are warranted.

Titania-Containing Bone Cement Shows Excellent Osteoconductivity in a Synovial Fluid Environment and Bone-Bonding Strength in Osteoporosis.

Titania bone cement (TBC) reportedly has excellent in vivo bioactivity, yet its osteoconductivity in synovial fluid environments and bone-bonding ability in osteoporosis have not previously been investigated. We aimed to compare the osteoconductivity of two types of cement in a synovial fluid environment and determine their bone-bonding ability in osteoporosis. We implanted TBC and commercial polymethylmethacrylate bone cement (PBC) into rabbit femoral condyles and exposed them to synovial fluid pressure. Rabbits were then euthanized at 6, 12, and 26 weeks, and affinity indices were measured to evaluate osteoconductivity. We generated a rabbit model of osteoporosis through bilateral ovariectomy (OVX) and an 8-week treatment with methylprednisolone sodium succinate (PSL). Pre-hardened TBC and PBC were implanted into the femoral diaphysis of the rabbits in the sham control and OVX + PSL groups. Affinity indices were significantly higher for TBC than for PBC at 12 weeks (40.9 ± 16.8% versus 24.5 ± 9.02%) and 26 weeks (40.2 ± 12.7% versus 21.2 ± 14.2%). The interfacial shear strength was significantly higher for TBC than for PBC at 6 weeks (3.69 ± 1.89 N/mm2 versus 1.71 ± 1.23 N/mm2) in the OVX + PSL group. These results indicate that TBC is a promising bioactive bone cement for prosthesis fixation in total knee arthroplasty, especially for osteoporosis patients.

What is the role of cemented fixation in total knee arthroplasty? The two-year results of a randomized RSA controlled trial.

For many designs of total knee arthroplasty (TKA) it remains unclear whether cemented or uncemented fixation provides optimal long-term survival. The main limitation in most studies is a retrospective or non-comparative study design. The same is true for comparative trials looking only at the survival rate as extensive sample sizes are needed to detect true differences in fixation and durability. Studies using radiostereometric analysis (RSA) techniques have shown to be highly predictive in detecting late occurring aseptic loosening at an early stage. To investigate the difference in predicted long-term survival between cemented, uncemented, and hybrid fixation of TKA, we performed a randomized controlled trial using RSA. A total of 105 patients were randomized into three groups (cemented, uncemented, and hybrid fixation of the ACS Mobile Bearing (ACS MB) knee system, implantcast). RSA examinations were performed on the first day after surgery and at scheduled follow-up visits at three months, six months, one year, and two years postoperatively. Patient-reported outcome measures (PROMs) were obtained preoperatively and after two years follow-up. Patients and follow-up investigators were blinded for the result of randomization. RSA secondary stabilization did not show a significant difference between the three types of fixation. A maximum total point motion of less than 0.2 mm in the second postoperative year was shown in each group, which suggests stabilization of the implant. At 24 months after surgery, PROMs significantly improved compared to baseline in all treatment groups. No significant difference was observed between the three groups. Secondary stabilization measurements in this study demonstrated no significant difference between the groups. In all groups migration stabilized after initial settling of the implant. For this implant the long-term outcome is not expected to be influenced by the type of fixation to the bone. Cite this article: Bone Joint J 2021;103-B(1):98-104.

No differences in cost-effectiveness and short-term functional outcomes between cemented and uncemented total knee arthroplasty

BackgroundThere is an ongoing debate regarding optimal fixation of total knee arthroplasty (TKA), however cost has not been addressed as profoundly. Therefore, the current study primarily aimed to compare costs and cost-effectiveness 1 year after cemented or uncemented TKA. A secondary objective was to compare short-term functional outcomes between both groups.MethodsA posthoc prospective observational multicenter cohort study of 60 cemented and 50 uncemented Low Contact Stress (LCS) knee systems. Outcome was evaluated using the EuroQol5D-3 L (EQ5D) index, in order to calculate quality adjusted life years (QALYs). Total costs were calculated considering direct costs within the hospital setting (inpatient cost) as well as direct and indirect costs outside the hospital. Cost-effectiveness (total costs per QALY), Oxford Knee Score (OKS) and Numeric Rating Scale (NRS) were compared between cemented and uncemented cases at 1 year after surgery. HealthBASKET project, a micro-costing approach, represents the Dutch costs and situation and was used to calculate hospital stay. (In) direct costs outside the healthcare (medical cost and productivity cost) were determined using two validated questionnaires.ResultsMedian costs per QALY were similar between cemented and uncemented TKA patients (€16,269 and €17,727 respectively; p = 0.50). Median OKS (44 and 42; p = 0.79), EQ5D (0.88 and 0.90; p = 0.82) and NRS for pain (1.0 and 1.0; p = 0.48) and satisfaction (9.0 and 9.0; p = 0.15) were also comparable between both groups.ConclusionFor this type of knee implant (LCS), inpatient hospital costs and costs after hospitalization were comparable between groups.

Hydroxyapatite-coated implants provide better fixation in total knee arthroplasty. A meta-analysis of randomized controlled trials.

BackgroundThe potential advantages of hydroxyapatite (HA)-coated cementless total knee arthroplasty (TKA) implants are bone stock preservation and biological fixation. Studies comparing the outcomes of HA-coated cementless, non HA-coated cementless (uncemented) and cemented TKA implants reported contradictory data. Our aim was to provide a comparison of the effects of HA coating of tibial stem on the stability and functionality of TKA implants.MethodsA systematic literature search was performed using MEDLINE, Scopus, EMBASE and the CENTRAL databases up to May 31st, 2019. The primary outcome was Maximum Total Point Motion (MTPM) of the tibial stem. This parameter is determined by radiosterometric analysis and refers to the migration pattern of the prosthesis stems. The clinical outcomes of the implanted joints were evaluated by the Knee Society Knee Score (KSS) and the Knee Society Function Score (KFS). Weighted mean difference (WMD) with 95% confidence interval (CI) were calculated with the random-effects model.ResultsAltogether, 11 randomized controlled trials (RCTs) with 902 patients for primary TKA implants were included. There was a statistically significant difference in the MTPM values with the use of HA-coated and uncoated uncemented implants (WMD = +0.28, CI: +0.01 to +0.56, P<0.001). However, HA-coated stems showed significantly higher migration when compared with the cemented prostheses (WMD = -0.29, CI: -0.41 to -0.16, P<0.001). The KSS values of HA-coated implants were significantly higher than those for the uncemented implants; moreover, KSS and KFS outcome scores were statistically not different between the HA-coated and cemented prosthesis cases.ConclusionHA-coating yields better stability than other, uncemented prostheses. More importantly, the HA-coating is not outperformed by cemented prosthesis in providing good functional outcome.

Cementless Fixation for Total Knee Arthroplasty in Various Patient Populations: A Literature Review.

The number of total knee arthroplasties (TKAs) performed in the United States has increased considerably in recent years, with a major contribution from younger patients. Maximizing survivorship of these implants has always been a point of emphasis. Early TKA designs with cementless fixation were associated with high rates of complications and implant failures. However, recent advances in cementless designs have shown excellent results. The decision to use cemented or cementless fixation for patients undergoing TKA is typically based on the surgeon's experience and preference. However, several patient characteristics must also be taken into account. The purpose of this review was to describe the clinical outcomes of studies in which a cementless TKA system was utilized for patients who (1) were less than 60 years of age, (2) were greater than 75 years of age, (3) were obese, (4) had rheumatoid arthritis, and (5) had osteonecrosis of the knee. Based on the studies included in this review, it appears that cementless fixation is a viable option for patients who have all of the above demographics.

Hybrid fixation versus full-cemented or full-cementless fixation in total knee arthroplasty: Systematic review and meta-analysis of comparative studies

ObjectiveHybrid fixation is one alternative to full-cemented fixation in total knee arthroplasty (TKA) with theoretical advantages. Hybrid fixation may offer the advantages of cementless femoral fixation, while also avoiding the problem of tibial loosening in full-cementless TKA. The purpose of the study is to determine whether hybrid TKA may perform comparably to or better than full-cemented and full-cementless TKA. MethodsWe searched the MEDLINE, EMBASE and Cochrane Library databases through September 2018 for randomized controlled trials and observational studies comparing outcomes of hybrid versus full-cemented or full-cementless fixation techniques. Outcomes of interest included aseptic loosening, overall reoperation rate, infection, radiolucent lines and operating time. Data were pooled with the Mantel–Haenszel random effects model. ResultsWe included 14 studies with follow-up ranging from 2.7 to 9.6 years in our quantitative analysis, of which 7 studies compared hybrid fixation with full-cemented TKA and another 7 compared hybrid fixation with full-cementless TKA. Combined data revealed that the hybrid fixation group had a similar rate of aseptic loosening compared with cemented (P = 0.19) and cementless (P = 0.49) groups. There was no difference with respect to other outcomes, including overall reoperation rate, infection, radiolucent lines and operating time between groups. ConclusionHybrid, cementless and cemented TKAs have comparable mid-term results as it pertains to aseptic loosening, overall reoperation, infection, radiolucent lines and operating time. Further comparative studies are needed to investigate these potential effects over the long-term.

Greater Blood Loss in Contemporary Cementless Total Knee Arthroplasty than Cemented Total Knee Arthroplasty despite Tranexamic Acid Use: A Match-Controlled Retrospective Study.

The purpose of this retrospective study was to assess whether tranexamic acid (TXA) reduces blood loss in cementless total knee arthroplasty (TKA) comparable to levels observed with cemented fixation. After exclusions from 109 consecutive TKAs, 76 cementless knees were matched to 78 cemented knees of identical implant and surgeon. Blood loss with and without TXA was compared. There was no difference between cohorts in sex, age, body mass index, American Society of Anesthesiologists Physical Status classification, or preoperative hemoglobin (p ≥ 0.119). Use of TXA reduced median drain output by only 205 mL in cementless knees compared to 470 mL in cemented knees (p < 0.001). Median drain output per hour was highest in cementless knees without TXA (39.5 mL) followed by cemented knees without TXA (38.2 mL), cementless knees with TXA (28.5 mL), and cemented knees with TXA (12.7 mL; p < 0.001). Hemoglobin drop and total blood loss did not differ between cohorts regardless of TXA use. Cementless fixation in TKA resulted in greater intra-articular blood loss as measured by drain output, despite the use of TXA. Further research is warranted to examine whether a higher TXA dose, TXA delivery method, or the application of bone wax sealant would mitigate blood loss in cementless TKA, and subsequently whether intra-articular blood accumulation resulting in postoperative hemarthrosis affects recovery, function, and clinical outcomes.

Despite Improved Survivorship of Uncemented Fixation in Total Knee Arthroplasty for Osteoarthritis, Cemented Fixation Remains the Gold Standard: An Analysis of a National Joint Registry

BackgroundTotal knee arthroplasty (TKA) numbers are increasing worldwide. While cement fixation for both femoral and tibial components is commonly used, alternatives include hybrid and uncemented TKAs. This study aimed to evaluate survivorship, revision rates, and patient-reported outcomes for cemented, hybrid, and uncemented TKAs using New Zealand Joint Registry (NZJR) data. MethodsNZJR data relating to all TKAs performed during the 19 years up to the end of December 2017 were analyzed. Outcomes were assessed using prosthesis survivorship data (including reasons for revision) and Oxford scores at 6 months, 5 years, and 10 years postoperatively. ResultsA total 96,519 primary TKAs were performed during the period examined. Most (91.5%) were fully cemented with 4.8% hybrid and 3.7% uncemented. Mean Oxford scores at 6 months were highest in cemented and lowest in uncemented TKAs (P < .001). However, this was not clinically significant. There was no difference at 5 or 10 years. Ten-year survival rates were 97%, 94.5%, and 95.8% for cemented, uncemented, and hybrid TKAs, respectively. Revision rates were 0.47, 0.74, and 0.52 per 100 component years for cemented, uncemented, and hybrid prostheses, respectively. The revision rate for uncemented prostheses compared with cemented was higher (P < .001). When stratified by age group, there were differences in survival rates between cemented and uncemented groups (P = .001) and hybrid and uncemented groups (P = .038) in patients aged <55 years; between cemented and uncemented groups in those aged 55-64 years (P = .031); and between cemented and hybrid groups in those aged >75 years (P = .004). ConclusionUncemented TKAs had similar patient-reported outcomes but higher revision rates and worse survivorship compared with hybrid or fully cemented TKAs.

To Cement or Not? Five-Year Results of a Prospective, Randomized Study Comparing Cemented vs Cementless Total Knee Arthroplasty

BackgroundThe optimal mode of fixation in total knee arthroplasty is a continuing subject of debate. MethodsPreviously, we reported 2-year results for this prospective, randomized trial. Knee Society Scores, Oxford scores, and pain visual analog scales were collected pre-operatively and post-operatively. Minimum 5-year follow-up has been obtained with radiographic analysis for 85 patients. ResultsMean Knee Society Scores and Oxford scores and patient-reported outcomes were similar in both groups. Each group had 1 additional revision, but neither was related to implant fixation. Survivorship with revision as an endpoint was equivalent (95.9% and 95.3%, P = .98). There was no significant difference in radiolucencies observed between groups (P = .10), all were non-progressive. ConclusionCementless and cemented total knee arthroplasty had equivalent patient-reported outcomes and survivorship at midterm follow-up. Updates are planned at 10 and 15-year intervals to observe long-term modes of failure between these 2 methods of fixation.

Postoperative Infection in Cementless and Cemented Total Knee Arthroplasty: A Propensity Score Matched Analysis.

The ongoing debate on fixation in total knee arthroplasty (TKA) has become increasingly relevant with its increased use in a younger patient population and the advent of novel cementless prostheses. Recent literature suggests modern cementless implants are comparable to their cemented counterparts in terms of survivorship and functional outcomes. What has not been well-assessed is whether the two modalities differ with respect to infection rates which was the purpose of this study. Specifically, a propensity score matched study population was used to compare: (1) overall infection; (2) prosthetic joint infection (PJI); and (3) surgical site infection (SSI) rates between cementless and cemented TKAs. Using a large institutional database, 3,180 consecutive primary TKAs were identified. Cementless and cemented TKA patients were propensity score matched by age (p = 0.069), sex (p = 0.395), body mass index (BMI; p = 0.308), and Charlson's comorbidity index (CCI) score (p = 0.616) in a 1:1 ratio. Univariate analysis was performed to compare 2-year overall infection rates. Infections were further analyzed separately as PJIs (deep joint infections requiring surgery) and SSIs (skin/superficial wound infections). Multivariate logistic regression was performed to evaluate infection incidences after adjusting for procedure-related factors (i.e., operative time, hospital volume, and surgeon volume). There were no significant differences between the matched cohorts in terms of overall infection rates (3.8 vs. 2.3%, p = 0.722), as well as when PJI (p = 1.000) and SSI (p = 1.000) rates were analyzed separately. Multivariate analysis revealed no significant differences in overall postoperative infection rates (p = 0.285), PJI rates (p = 0.446), or SSI rates (p = 0.453) even after adjusting for procedure-related factors. There is increasing literature investigating various outcomes demonstrating the comparable efficacies of cementless versus cemented TKAs. To the best of the author's knowledge, this was the first matched case-control study to directly compare their post-operative infection rates. The findings from this study show that post-operative infection rates were similar between fixation modalities even after accounting for a range of patient- and procedure-related factors.

Midterm Results of Cementless Total Knee Arthroplasty: A Retrospective Case Series.

Background:There is an ongoing debate about whether to use cementless or cemented fixation for Total Knee Arthroplasty (TKA).Objective: The study aimed to assess midterm survivorship of the Vanguard cementless system, and to demonstrate the utility of the Bone Hardness Test (BHT) for the selection of cementless fixation TKA.Methods:From September 2009 through November 2014, 123 total knee arthroplasties were completed, with cementless Vanguard Cruciate Retaining TKA in 110 knees (102 patients) and cemented Vanguard in 13 cases (12 patients). Implant fixation was based on intraoperative assessment of posterior cruciate ligament stability, bone quality, and BHT. All patients with a cementless Vanguard implant were eligible for this retrospective study. Preoperative and postoperative Knee Society Score and Western Ontario and McMaster Universities Osteoarthritis Index were obtained. Standardized standing anteroposterior and lateral radiographs were taken.Results:Three patients (4 TKAs) were lost to follow-up. The mean follow-up time was 5.5 ± 1.4 years. All scores significantly improved postoperatively. No radiographic failures were observed. Five-year implant survival, with revision of any component for any reason as an endpoint, was 97.2% (95% confidence interval, 91.7 - 99.1%). Five-year survival with revision for aseptic loosening was 100%. Only one knee required revision due to an isolated unrelated bearing exchange, and two additional knees required secondary resurfacing of the patella for retropatellar pain.Conclusion:Good midterm results were obtained with the cementless Vanguard Cruciate Retaining TKA for the treatment of osteoarthritis. The Bone Hardness Test appears to be an effective way to determine the selection of cementless TKA.

Uncemented Tantalum Monoblock Tibial Fixation for Total Knee Arthroplasty in Patients Less Than 60 Years of Age: Mean 10-Year Follow-up.

Although tibial component loosening has been considered a concern after total knee arthroplasty without cement, such implants have been used in younger patients because of the potential for ingrowth and preservation of bone stock. However, mid-term and long-term studies of modern uncemented implants are lacking. We previously reported promising prospective 5-year outcomes after using an uncemented porous tantalum tibial component in patients who underwent surgery before the age of 60 years. The purpose of this study was to determine clinical and radiographic implant survivorship at 10 years in this large series of young patients. The original cohort included 79 patients (96 knees) who were <60 years old at the time of surgery. All procedures were performed with an uncemented, posterior-stabilized femoral component and a porous tantalum monoblock tibial component by 1 high-volume arthroplasty surgeon at a single institution. Patients were followed prospectively. The Knee Society Score (KSS), radiographic findings, and any complications or revisions were recorded. At the latest follow-up, 76% (60) of the 79 patients (74% [71] of the 96 knees) were available for evaluation or had undergone revision (n = 6); 7 patients had died with the implants in place, and 12 patients were lost to follow-up. The average follow-up for the available implants was 10 years (range, 8 to 12 years). There were no progressive radiolucencies on radiographic review. The mean functional KSS was 68 points (range, 0 to 100 points). All revisions were for reasons unrelated to tibial fixation: femoral component loosening (1), stiffness (1), pain and swelling (2), and instability (2). The all-cause revision rate was 6% (6 of 96 knees). Uncemented porous tantalum monoblock tibial components provided reliable fixation, excellent radiographic findings, and satisfactory functional outcomes at a mean of 10 years postoperatively. We identified no cases of tibial component loosening. These promising clinical and radiographic results support the use of uncemented tibial components. Such implants may produce well-integrated, durable long-term constructs in young patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.