Orthopedics

Cementless Tibial Fixation in TKA: Not a Second Coming

John J. Callaghan, MD; Steve S. Liu, MD

  • Orthopedics. 2010;33(9)
  • Posted September 1, 2010

Abstract

Cemented total knee arthroplasty (TKA), using mechanically sound components such as the total condylar system (Johnson & Johnson, New Brunswick, New Jersey), have been performed for >25 years. Long-term follow-up studies have shown excellent durability. In 1 series with a minimum 20-year follow-up, the revision rate for aseptic loosening was 3.5%. More contemporary prostheses, such as the low contact stress rotating platform (DePuy, Warsaw, Indiana) and Kinematic knee systems (Howmedica, Rutherford, New Jersey), have demonstrated minimal loosening at 20-year follow-up. In a minimum 20-year follow-up of a rotating platform TKA, the revision rate for aseptic loosening was 0%. In a minimum 15-year follow-up of kinematic cruciate-retaining TKA, the revision rate for aseptic loosening was 1.8%. Cemented fixation is durable and forgiving. It can accommodate defects in bone as well as imperfect cuts that are not uncommon, even in the best of hands. It can interdigitate into soft and hard bone. With the development of modular tibial trays with better locking mechanisms and less abrasive surfaces, as well as the development of more wear-resistant polyethylene (gamma irradiated in an inert environment and crosslinked polyethylene), the osteolysis that developed around first generation modular components should be markedly less with newer designs. It is for these reasons that cement should remain the fixation of choice in TKA.

Why should one consider using cement for fixation in total knee arthroplasty (TKA)? In short, it works, it is durable, it provides predictable clinical results, and it rarely fails.

Rodriguez et al1 reported on a cohort of 220 total condylar knee replacements with 14 revisions at 20-year follow-up. Only 7 of the revisions were for aseptic loosening, most of which were on the tibial side, for a revision rate of 3.2%. Average Knee Society clinical and functional scores and motion were 88, 58, and 100°, respectively. Radiographically, some incomplete radiolucencies were reported, but none were circumferential. Pavone et al2 corroborated these results in 120 total condylar knees with an 8.3% revision rate and 91% survivorship at 23 years.

How about studies with posterior cruciate-retaining designs? The Mayo Clinic reported on 168 Kinematic-I condylar total knees (Howmedica, Rutherford, New Jersey) at 15-year follow-up with only 3 knees revised for aseptic loosening.3 Ritter et al4 have reported similar data with a posterior cruciate-retaining design with 98% survival at 15 years. In a more contemporary design, Berger et al5 have reported on a cohort of Miller-Galante-I and Miller-Galante-II knees at average 11-year follow-up. The Miller-Galante-I cohort had a 12.2 revision rate, but all were related to the patella. When looking at 10-year survival of the cemented tibias, it was 100%.

What about posterior cruciate-substituting designs? Brassard et al6 reported on minimum 10-year results of 165 Insall-Burstein I and 160 Insall-Burstein II cemented total knees with no revisions in either group.

We have had the opportunity to look up our results with the low contact stress mobile bearing, rotating platform design total knee at minimum 20-year follow-up.7 Of the 119 knees, none were revised for loosening (Figure) and only 1 femoral component was loose at 20 years.

Can results similar to the success of cemented fixation be obtained with cementless fixation? Hofmann et al8 and Whiteside9 have reported survivorship of 98% at 15 to 18 years, and 93% at 12 years, respectively, using cementless fixation. Hence, excellent results can be obtained with cementless TKA.

When evaluating studies in the literature comparing cemented and cementless fixation, it is evident that cementless fixation has not held up as well. Barrack et al10 reported on a minimum 2-year follow-up of cemented and cementless low contact stress knees. None of the 66 knees in…

Abstract

Cemented total knee arthroplasty (TKA), using mechanically sound components such as the total condylar system (Johnson & Johnson, New Brunswick, New Jersey), have been performed for >25 years. Long-term follow-up studies have shown excellent durability. In 1 series with a minimum 20-year follow-up, the revision rate for aseptic loosening was 3.5%. More contemporary prostheses, such as the low contact stress rotating platform (DePuy, Warsaw, Indiana) and Kinematic knee systems (Howmedica, Rutherford, New Jersey), have demonstrated minimal loosening at 20-year follow-up. In a minimum 20-year follow-up of a rotating platform TKA, the revision rate for aseptic loosening was 0%. In a minimum 15-year follow-up of kinematic cruciate-retaining TKA, the revision rate for aseptic loosening was 1.8%. Cemented fixation is durable and forgiving. It can accommodate defects in bone as well as imperfect cuts that are not uncommon, even in the best of hands. It can interdigitate into soft and hard bone. With the development of modular tibial trays with better locking mechanisms and less abrasive surfaces, as well as the development of more wear-resistant polyethylene (gamma irradiated in an inert environment and crosslinked polyethylene), the osteolysis that developed around first generation modular components should be markedly less with newer designs. It is for these reasons that cement should remain the fixation of choice in TKA.

Why should one consider using cement for fixation in total knee arthroplasty (TKA)? In short, it works, it is durable, it provides predictable clinical results, and it rarely fails.

Cemented Fixation

Rodriguez et al1 reported on a cohort of 220 total condylar knee replacements with 14 revisions at 20-year follow-up. Only 7 of the revisions were for aseptic loosening, most of which were on the tibial side, for a revision rate of 3.2%. Average Knee Society clinical and functional scores and motion were 88, 58, and 100°, respectively. Radiographically, some incomplete radiolucencies were reported, but none were circumferential. Pavone et al2 corroborated these results in 120 total condylar knees with an 8.3% revision rate and 91% survivorship at 23 years.

How about studies with posterior cruciate-retaining designs? The Mayo Clinic reported on 168 Kinematic-I condylar total knees (Howmedica, Rutherford, New Jersey) at 15-year follow-up with only 3 knees revised for aseptic loosening.3 Ritter et al4 have reported similar data with a posterior cruciate-retaining design with 98% survival at 15 years. In a more contemporary design, Berger et al5 have reported on a cohort of Miller-Galante-I and Miller-Galante-II knees at average 11-year follow-up. The Miller-Galante-I cohort had a 12.2 revision rate, but all were related to the patella. When looking at 10-year survival of the cemented tibias, it was 100%.

What about posterior cruciate-substituting designs? Brassard et al6 reported on minimum 10-year results of 165 Insall-Burstein I and 160 Insall-Burstein II cemented total knees with no revisions in either group.

We have had the opportunity to look up our results with the low contact stress mobile bearing, rotating platform design total knee at minimum 20-year follow-up.7 Of the 119 knees, none were revised for loosening (Figure) and only 1 femoral component was loose at 20 years.

Figure A: Bilateral TKA 20 years prior Figure B: Bilateral TKA 20 years prior
Figure C: Bilateral TKA 20 years prior Figure: Preoperative (A), postoperative (B), and 20-year follow-up (C) radiographs of an 85-year-old woman who had bilateral TKA 20 years prior. At final follow-up, she walked unlimitedly with no support. She had no pain in her right knee and mild pain in her left knee. Range of motion was 0° to 110° in both knees.

Cementless Fixation

Can results similar to the success of cemented fixation be obtained with cementless fixation? Hofmann et al8 and Whiteside9 have reported survivorship of 98% at 15 to 18 years, and 93% at 12 years, respectively, using cementless fixation. Hence, excellent results can be obtained with cementless TKA.

Cemented vs Cementless Fixation

When evaluating studies in the literature comparing cemented and cementless fixation, it is evident that cementless fixation has not held up as well. Barrack et al10 reported on a minimum 2-year follow-up of cemented and cementless low contact stress knees. None of the 66 knees in the cemented group required revision while 6 of the 73 knees in the cementless group were revised. Duffy et al11 reported on press-fit condylar total knees at a mean 10-year follow-up. Survivorship for the cemented group was 94%, while the cementless group had 72% survivorship. Fehring et al12 has reported that in an analysis of early failures of TKAs, 13% were revised for failure of cementless components to obtain bony ingrowth, which was the third most common cause for revision (after infection and instability).

However, in regard to cemented and cementless designs, the results have not always been comparable. In terms of concerns with osteolysis, it was first reported with cementless devices. Perhaps this is why Whiteside13 has had so many different designs of his prosthesis in hopes of addressing this issue. For cardiopulmonary issues, Dorr et al14 have reported that there are no differences in terms of cemented versus cementless fixation.

Cemented Modular Components

Potential concerns exist for cemented modular components. We have reported on cemented modular press-fit condylar total knees at minimum 15 years with 6% revision rate, all for wear, or wear with osteolysis.15 In another series of knees in patients 55 years and younger, we reported a revision rate of 16% at minimum 10-year follow-up. All were related to osteolysis.16 Backside wear with motion between the insert and tray, as well as cam post impingement, are contributing causes of osteolysis.17,18

Conclusion

Given the long-term track record of the success of cemented fixation in TKA, there is no need to change to cementless fixation. Cemented fixation is durable and allows for acute fixation with long-term durability and without relying on perfect cuts and supplemental fixation required to achieve bony ingrowth into cementless fixation (which can be problematic, especially on the tibial side of the construct).

References

  1. Rodriguez JA, Bhende H, Ranawat CS. Total condylar knee replacement: a 20-year followup study. Clin Orthop Relat Res. 2001; (388):10-17.
  2. Pavone V, Boetttner F, Fickert S, Sculco TP. Total condylar knee arthroplasty: a long-term followup. Clin Orthop Relat Res. 2001; (388):18-25.
  3. Sextro GS, Berry DJ, Rand JA. Total knee arthroplasty using cruciate-retaining kinematic condylar prosthesis. Clin Orthop Relat Res. 2001; (388):33-40.
  4. Ritter MA, Berend ME, Meding JB, Keating EM, Faris PM, Crites BM. Long-term followup of Anatomic Graduated components posterior cruciate-retaining total knee replacement. Clin Orthop Relat Res. 2001; (388):51-57.
  5. Berger RA, Rosenberg AG, Barden RM, Sheinkop MB, Jacobs JJ, Galante JO. Long-term followup of the Miller-Galante total knee replacement. Clin Orthop Relat Res. 2001; (388):58-67.
  6. Brassard MF, Insall JN, Scuderi GR, Colizza W. Does modularity affect clinical success? A comparison with a minimum 10-year follow-up. Clin Orthop Relat Res. 2001; (388):26-32.
  7. Callaghan JJ, Wells CW, Liu SS, Goetz DD, Johnston RC. Cemented rotating-platform total knee replacement: a concise follow-up, at a minimum of twenty years, of a previous report. J Bone Joint Surg Am. 2010; 92(7):1635-1639.
  8. Hofmann AA, Evanich JD, Ferguson RP, Camargo MP. Ten-to 14-year clinical followup of the cementless Natural Knee system. Clin Orthop Relat Res. 2001; (388):85-94.
  9. Whiteside LA. Long-term followup of the bone-ingrowth Ortholoc knee system without a metal-backed patella. Clin Orthop Relat Res. 2001; (388):77-84.
  10. Barrack RL, Hakamura SJ, Hopkins SG, Rosenweig S. 2003 James A. Winner of the 2003 James A. Rand Young Investigator’s Award. Early failure of cementless mobile-bearing total knee arthroplasty. J Arthroplasty. 2004; 19(7 Suppl 2):101-106.
  11. Duffy GP, Berry DJ, Rand JA. Cement versus cementless fixation in total knee arthroplasty. Clin Orthop Relat Res. 1998; (356):66-72.
  12. Fehring TK, Odum S, Griffin WL, Mason JB, Nadaud M. Early failures in total knee arthroplasty. Clin Orthop Relat Res. 2001; (392):315-318.
  13. Whiteside LA. Effect of porous-coating configuration on tibial osteolysis after total knee arthroplasty. Clin Orthop Relat Res. 1995; (321):92-97.
  14. Dorr LD, Merkel C, Mellman MF, Klein I. Fat emboli in bilateral total knee arthroplasty. Predictive factors for neurologic manifestations. Clin Orthop Relat Res. 1989; (248):112-118; discussion 118-119.
  15. Malin AS, Callaghan JJ, Bozic KJ, et al. Routine surveillance of modular PFC TKA shows increasing failures after 10 years [published online ahead of print March 19, 2010]. Clin Orthop Relat Res. 2010; 468(9):2469-2476.
  16. Odland AN, Callaghan JJ, Liu SS, Wells CW. Wear and lysis is the problem in modular TKA in the young OA patient at 10 years. Clin Orthop Relat Res. 2010. In Press.
  17. Callaghan JJ, O’Rourke MR, Goetz DD, Schmalzried TP, Campbell PA, Johnston RC. Tibial post impingement in posterior-stabilized total knee arthroplasty. Clin Orthop Relat Res. 2002; (404):83-88.
  18. Engh GA, Lounici S, Rao AR, Collier MB. In vivo deterioration of tibial baseplate locking mechanisms in contemporary modular total knee components. J Bone Joint Surg Am. 2001; 83(11):1660-1665.

Authors

Drs Callaghan and Liu are from the University of Iowa, and Dr Callaghan is also from VA Medical Center, Iowa City, Iowa.

Dr Callaghan has received royalties from DePuy. Dr Liu has no relevant financial relationships to disclose.

Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.

Correspondence should be addressed to: John J. Callaghan, MD, 200 Hawkins Dr, UIHC, 01029 JPP, Iowa City, IA 52242 (john-callaghan@uiowa.edu).

doi: 10.3928/01477447-20100722-26

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