Cementless Total Knee Arthroplasty: A Resurgence-Who, When, Where, and How?

Comparing Facility Costs, Patient-Reported Outcome Measures, and Revision Rates in Cementless and Cemented Primary Total Knee Arthroplasty: Findings from a Propensity Score Matched Patient-Level Value Analysis of 380 Procedures with Mean 4.3-Year Follow-Up

BACKGROUND

Healthcare value accounts for clinical outcomes and cost. A methodology for more accurate cost accounting is time-driven activity-based costing (TDABC). No prior study has evaluated the value of cementless total knee arthroplasty (TKA) using TDABC.

METHODS

We performed a retrospective propensity score-matched analysis of 76 cementless TKAs and 304 cemented TKAs with a mean follow-up of 4.3 years (range, 1.7 to 8.5 years). Reference pricing for implants was used, and cementless implants were available at a premium price relative to reference pricing. Value was the primary outcome and was defined twofold: Absolute Value KOOS-PS was the quotient of 1-year Knee Osteoarthritis Outcome Score-Physical Function Short-Form KOOS-PS and facility cost; Incremental Value KOOS-PS was the quotient of delta KOOS-PS and facility cost. Revision rate was also compared, but not factored into our value equation.

RESULTS

Cementless TKAs had significantly higher total facility costs than cemented TKAs (971 versus 800 cost units [CUs]; percent difference: +21.4%; P < 0.001). The cost difference was principally related to cementless TKAs having higher implant costs (542 versus 367 CUs; percent difference: +47.7%; P < 0.001). There were no significant differences in KOOS-PS scores. Cementless TKA was found to have significantly reduced mean Absolute Value KOOS-PS (48.3 versus 58.1; P < 0.001) and Incremental Value KOOS-PS (16.5 versus 20.3; P = 0.038). The revision rate at the mean 4.3-year follow-up was low and similar (3.9 versus 2.3%; P = 0.42).

CONCLUSION

We compared value (defined as 1-year PROMs relative to facility costs) between cementless and cemented TKA. Cementless TKAs demonstrate lower value at a mean 4.3-year follow-up due to differences in implant cost. Increased value for cementless TKA is ultimately plausible if reductions in revision rates beyond 5-year follow-up are observed or if cementless TKA implants are incorporated in reference pricing matrices to reduce their cost.

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

BACKGROUND

The optimal mode of fixation for total knee arthroplasty (TKA) continues to be a subject of debate.

METHODS

There were 100 cases enrolled to compare cemented and cementless TKA using a modular trabecular metal tibia. This is a report on the 91 cases with follow-up information, including 67 cases with a minimum 10-year follow-up: 36 cases in the cemented cohort (A) and 31 cases in the cementless cohort (B). We previously reported the 2- and 5-year results for this prospective, randomized trial. Knee Society Scores and Oxford scores were collected preoperatively and postoperatively.

RESULTS

The mean Knee Society Scores (94.4, 89.1, P = 0.21) and Oxford scores (44.1, 43.9, P = 0.80) were similar in both groups. Group A had two revisions at 5-year follow-up, with three additional revisions for polyethylene wear, osteolysis, and loosening at 10-year follow-up. Group B had two revisions at 5-year follow-up, with two additional revisions for polyethylene wear and instability and instability due to laxity at 10-year follow-up. In total, two group A cases and one group B case were revised for implant fixation complications. Survivorship with any revision as an end point was equivalent between the two cohorts (91.5%, 95.9%, P = 0.60), as was survivorship using tibial tray revision as an end point (93.7%, 95.9%, P = 0.55). No cases demonstrated any progressive radiolucencies. Group A had 5 cases with osteolysis (80% tibial), and Group B had two cases of osteolysis (0% tibial).

CONCLUSIONS

Cementless and cemented TKA had equivalent patient-reported outcomes and survivorship at 10-year follow-up. Cemented fixation had a higher rate of osteolysis and loosening, which may be related to increased third-body wear. Cementless fixation shows immense potential as a successful option for many patients. Updates to this study cohort are planned at 15- and 20-year intervals to obtain longer-term outcomes.

Improved performance of cementless total knee arthroplasty (TKA)across international registries: a comparative review

BACKGROUND

Cementless fixation in total knee arthroplasty (TKA) has been associated with higher revision rates in the past. However, due to advancements in design, as well as surgical techniques, cementless TKA performance has significantly improved. The advantages of cementless fixation include reduced cement-related complications, shorter operating times, and the potential benefits of osseointegration. We aim to assess the improvement in revision rates for cementless TKA over the last 9 years based on international registry reports.

METHODS

A comprehensive retrospective review was conducted of six major English-speaking knee arthroplasty registries across the world including the National Joint Registry of England and Wales, Northern Islan Isle of Man and Guernsey (herby referred to as British), Swedish, Canadian, American, Australian, and New Zealand National Joint Registry. Data was collected from the year 2014 along with the most recent annual report published: 2022 or 2023. Data points collected included usage rates of cemented and cementless prostheses for primary TKA, their respective revision rates, and indications for revision.

RESULTS

Across four databases, there was an average 8.3% increase in the utilization of cementless fixation for primary TKA over the past decade. Three registries reported a reduction in revision rates for cementless fixation. Lower revision rates for cementless compared to cemented TKA were observed in the most recent American (3.2% cemented vs. 2.8% cementless) and New Zealand annual reports (11.8% cemented vs. 4.5% cementless). In 2022, the British registry reported lower rates of revision for infection with cementless fixation (0.56 vs. 0.89).

CONCLUSION

International registries demonstrate increased utilization of cementless TKA. Cementless TKA was reported to have lower revision rates in the most recent US and New Zealand annual reports when compared to cemented TKA.

Uncemented Total Knee Arthroplasty in the State of Michigan has Higher Rates of Revision Through 5-Year Follow-Up

BACKGROUND

While cemented total knee arthroplasty (TKA) is considered the gold standard, uncemented designs are gaining popularity, especially in young men who are at higher risk of cemented failure. Assessing this growth's impact, the Michigan Arthroplasty Registry Collaborative Quality Initiative analyzed adoption rates of uncemented TKA and the effect of fixation technique on revision rates with the goal of assessing the revision rates and survivorship at five years of cemented versus uncemented TKA to further classify which patients may be more ideal candidates for cementless fixation.

METHODS

The Michigan Arthroplasty Registry Collaborative Quality Initiative data from 2017 to 2022 was analyzed to determine the survivorship of cemented versus uncemented TKAs. Descriptive statistics, demographics, and implant type were collected. Cumulative percent revision (CPR) was calculated based on the fixation method. The primary endpoint was time for the first revision. Kaplan-Meier survival curves were compared. Subanalyses were performed based on age, sex, body mass index, and implant type. Confidence intervals were set to 95%.

RESULTS

The registry query yielded 147,838 TKAs. There were 18,523 (12.5%) uncemented TKAs. Uncemented TKA use increased yearly from 2017 to 2022 in all groups. Uncemented TKA had higher CPR through five years at all time points versus cemented (3.65 versus 3.19%, P < 0.0001). Uncemented TKA performed worse in both men and women (P < 0.01, P < 0.01). Unexpectedly, men < 55 years had higher CPR at all time points for the four most used implants (P < 0.05).

CONCLUSIONS

The use of uncemented TKA has grown in Michigan across all patient subgroups. Uncemented TKAs had an overall higher risk of revision compared to cemented TKAs. The poorer outcomes appeared consistent across sex, age, and implant type. Younger men who are often preferred for uncemented fixation had higher failure rates. This study suggests that surgeons should be mindful of revision rates and patient selection when moving to uncemented TKA.

Fixation options for total knee arthroplasty: a comprehensive literature review

Total knee arthroplasty is a consistently successful, cost-efficient, and highly effective surgical procedure for treating severe knee osteoarthritis. The success and longevity of total knee arthroplasty depend significantly on the fixation method used to secure the prosthetic components. This comprehensive review examines the primary fixation methods (cemented, cementless, and hybrid fixation), analysing their biomechanics, clinical outcomes, advantages, and disadvantages, focusing on recent advances and trends in total knee arthroplasty fixation.

Cementless Total Knee Arthroplasty: A State-of-the-Art Review

» The demographic profile of candidates for total knee arthroplasty (TKA) is shifting toward younger and more active individuals.» While cemented fixation remains the gold standard in TKA, the interest is growing in exploring cementless fixation as a potentially more durable alternative.» Advances in manufacturing technologies are enhancing the prospects for superior long-term biological fixation.» Current research indicates that intermediate to long-term outcomes of modern cementless TKA designs are comparable with traditional cemented designs.» The selection of appropriate patients is critical to the success of cementless fixation techniques in TKA.» There is a need for high-quality research to better understand the potential differences and relative benefits of cemented vs. cementless TKA systems.