Cementless versus Cemented Fixation in Total Knee Arthroplasty

The Effect of Cemented Implants Placed During Initial TKA on Surgical Time and Expenses in Revision TKA

INTRODUCTION

Revision total knee arthroplasty (rTKA) is a complex procedure that often requires the removal of previous implants. There is little information evaluating the difference between removing cemented or noncemented knee prostheses in revision surgeries. The purpose of this study was to determine whether removing cemented or noncemented implants would affect surgical time and expenses incurred during revision procedures.

METHODS

This retrospective cohort study used a single-institution database to identify 300 patients who underwent femoral and tibial implant rTKA from 2016 to 2022 because of mechanical complications (infection cases excluded). Radiographs and surgical reports were used to confirm whether the fixation technique was cemented (N = 243) or noncemented (N = 57). The primary outcomes were surgical time and surgery costs. Secondary outcomes included readmission rates, revision implants used, stem usage, and insurance type.

RESULTS

The average surgical time was 121 minutes for noncemented and 128 minutes for cemented procedures (P = 0.118). The 90-day readmission rates for each group were similar at 7.00% for the cemented cohort and 8.77% for the noncemented cohort (P = 0.643). For patients with Medicare Advantage, the respective surgery costs were $1,966 for noncemented and $1,968 for cemented TKA (P = 0.988). For patients with commercial insurance, the respective surgery costs were $4,854 for noncemented and $5,660 for cemented TKA (P = 0.330).

CONCLUSION

Primary knee fixation type, cemented or noncemented, did not appear to influence the surgical duration or surgical costs of both-implant revision knee surgery indicated for mechanical complications.

Comparison of bilateral cementless total knee arthroplasty results between patients in different BMI groups

INTRODUCTION

The aim of this study was to compare the results of cementless bilateral total knee arthroplasty (TKA) between individuals in different obesity groups.

MATERIALS AND METHODS

This was a retrospective cohort study. Patients with a body mass index (BMI) greater than 25 who underwent bilateral TKA for gonarthrosis between 2014 and 2020 and completed a minimum follow-up of 24 months were included. Age, sex, height, weight, BMI, operation time, length of stay, patient satisfaction, knee scores and complications were compared. Patients with missing data, who were followed for less than 24 months or had postoperative fractures around the knee were excluded.

RESULTS

There was a significant difference between the groups in terms of operation time (Class III > overweight > Class II > Class I p < 0.001). There was a significant difference in complications between the groups (Class III > Class I > Class II > overweight p = 0.010). According to our pairwise comparison, complications were more common in the class III group than in the overweight group. Knee score (KS) and function score (FS) increased significantly after surgery in all groups (p < 0.001), with no difference in FS (p = 0.448). Knee score changes were greater in the overweight and class I groups (p < 0.001). There was a significant interaction between both KS and FS and person satisfaction (p < 0.001).

CONCLUSION

Cementless TKA improved KS and FS in all obesity groups, yielded high patient satisfaction. Although the incidence of complications was higher in the morbidly obese patients than in the overweight patients, the difference was not significant. Patients with morbid obesity should be informed about related risks before planning cementless TKA.

Cemented vs. Cementless Fixation in Primary Knee Replacement: A Narrative Review

Knee osteoarthritis (OA) is one of the leading causes of disability around the globe. Osteoarthritis is mainly considered a disease affecting the elderly. However, more and more studies show that sports overuse, obesity, or congenital disorders can initiate a pathologic cascade that leads to OA changes in the younger population. Nevertheless, OA mostly affects the elderly, and with increasing life expectancy, the disease will develop in more and more individuals. To date, the golden standard in the treatment of the end-stage of the disease is total joint replacement (TJR), which restores painless knee motion and function. One of the weakest elements in TJR is its bonding with the bone, which can be achieved by bonding material, such as poly methyl-methacrylate (PMMA), or by cementless fixation supported by bone ingrowth onto the endoprosthesis surface. Each technique has its advantages; however, the most important factor is the revision rate and survivor time. In the past, numerous articles were published regarding TJR revision rate, but no consensus has been established yet. In this review, we focused on a comparison of cemented and cementless total knee replacement surgeries. We introduced PICO rules, including population, intervention, comparison and outcomes of TJR in a PubMed search. We identified 783 articles published between 2010 and 2023, out of which we included 14 in our review. Our review reveals that there is no universally prescribed approach to fixate knee prostheses. The determination of the most suitable method necessitates an individualized decision-making process involving the active participation and informed consent of each patient.

Etiology of Total Knee Arthroplasty Revisions: A Two-Decade Institutional Perspective

Total knee arthroplasty (TKA) implant survival time is determined by various patient and implant-related factors and varies significantly in recent worldwide reports. In our study, we have included 247 TKA revisions in 203 patients performed in our hospital over the last 20 years. Multiple etiologies of revisions were identified and classified into 10 categories. Time to failure was analyzed with regard to etiology, patient demographics, and other relevant data. The overall average time to revision was 44.08 months (95% confidence interval (CI) between 33.34 and 49.82 months). Age at primary implant was negatively correlated with time to revision (hazard ratio (HR) = 1.0521 and 95% CI of HR = 1.0359 to 1.0685) and female patients showed a 1.59 times higher risk of implant failure than males. Periprosthetic joint infection was the cause of 46.56% (n=115) of revisions (out of which 12.55% (n=31) were early infections, diagnosed within the first three months), while aseptic loosening was found in 31.98% (n=79) of cases. Infection correlated with a shorter time to revision compared to aseptic loosening (p<0.05). These findings emphasize the need to intensify efforts to deliver the best patient care, select the best antibiotic regimen, and improve surgical techniques to decrease the incidence of infectious complications.

Mechanical complications after total knee arthroplasty

INTRODUCTION

With the increasing demand for total knee arthroplasty (TKA) and the burden of revision TKA on the healthcare system, as well as the quality of life implications for patients, it is extremely important for surgeons to be able to anticipate and prevent TKA mechanical complications. Surgeons must be familiar with the different causes and mechanisms of TKA complications so that they can properly treat patients with failed TKAs and better avoid these complications.

AREAS COVERED

This review addresses TKA mechanical complications and provides context for the topic. A detailed review of surgical factors, implant factors, and patient factors that contribute to mechanical complications after TKA is provided. All of the literature cited in this review was gathered from the PubMed online database using different keywords based on the section of the manuscript.

EXPERT OPINION

As surgeons and engineers solve certain issues in TKA, new challenges will inevitably arise. We must continue to push forward and innovate from both a surgical technique and implant design perspective.

Cementless Compared to Cemented Total Knee Arthroplasty is Associated With More Revisions Within 1 Year of Index Surgery

Background

Cementless total knee arthroplasties (TKAs) have gained renewed interest due to improved implant designs and lower rates of revision than its cemented counterparts. The purpose of this study was to compare revision rates between cemented vs cementless TKAs within 1 year of primary arthroplasty.

Methods

This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone cemented and cementless TKAs and subsequent surgical revisions. An unadjusted univariate analysis of patient demographics, Charlson Comorbidity Index score, and surgical revisions at 90 days and 1 year after TKA was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for 1-year surgical complications requiring revision.

Results

Of 324,508 patients, 312,988 (96.45%) underwent cemented TKAs, and 11,520 (3.55%) underwent cementless TKAs. Patients undergoing cementless TKA tended to be younger than patients undergoing cemented TKA (63.67 ± 9.15 cementless vs 66.22 ± 8.85 cemented, P < .001). Univariate chi-squared testing showed that cementless patients were more likely to require 1-component femoral or tibial revision at 90 days and 1 year, irrigation and debridement at 90 days and 1 year, and arthroscopy with lysis of adhesions at 1 year only. Similar findings were observed for these 3 revision procedures at 1 year after correcting for age, gender, and Charlson Comorbidity Index score using multivariate logistic regression analysis as cementless TKA patients had higher odds ratios for each of the revisions.

Conclusions

Small but significant differences were found in surgical revisions among cementless TKAs when compared to cemented TKAs within 1 year of the index procedure.

Manipulation Under Anesthesia is Safe After Cementless Total Knee Arthroplasty: A Multicenter Study

BACKGROUND

Cementless total knee arthroplasty (TKA) is thought to facilitate durable, biological fixation between the bone and implant. However, the 4-12 weeks required for osseointegration coincides with the optimal timeframe to perform a manipulation under anesthesia (MUA) if a patient develops postoperative stiffness. This study aims to determine the impact of early MUA on cementless fixation by comparing functional outcomes and survivorship of cementless and cemented TKAs.

METHODS

A consecutive series of patients who underwent MUA for postoperative stiffness within 90 days of primary, unilateral TKA at 2 academic institutions between 2014 and 2018 were identified. Cases involving extensive hardware removal were excluded. Cementless TKAs undergoing MUA (n = 100) were propensity matched 1:1 to cemented TKAs undergoing MUA (n = 100) using age, gender, body mass index, and year of surgery. Both groups had comparable baseline Knee Injury and Osteoarthritis Outcome Scores (KOOS), Short Form (SF)-12 Physical, and SF-12 Mental scores. MUA-related complications as well as postoperative KOOS and SF-12 scores were compared.

RESULTS

MUA-related complications were equivalently low in both groups (P = .324), with only 1 patella component dissociation in the cementless group. No tibial or femoral components acutely loosened in the perioperative period. Postoperative KOOS (P = .101) and SF-12 Mental scores (P = .380) were similar between groups. Six-year survivorship free from any revision after MUA was 98.0% in both groups (P = 1.000).

CONCLUSION

Early postoperative MUA after cementless TKA was not associated with increased MUA-related complications or worse patient-reported outcomes compared to cemented TKA. Short-term survivorship was also comparable, suggesting high durability of the bone-implant interface.

Current Trends in Knee Arthroplasty: Are Italian Surgeons Doing What Is Expected?

Objectives: The purpose of this study is to evaluate Italian surgeons’ behavior during knee arthroplasty. Materials and Methods: All orthopedic surgeons who specialized in knee replacement surgeries and were members of the Italian Society of Knee, Arthroscopy, Sport, Cartilage and Orthopedic Technologies (SIGASCOT) between January 2019 and August 2019 were asked to complete a survey on the management of knee arthroplasty. Data were collected, analyzed, and presented as frequencies and percentages. Results: One-hundred and seventy-seven surgeons completed the survey and were included in the study. Ninety-five (53.7%) surgeons were under 40 years of age. Eighty-five surgeons (48%) worked in public hospitals and 112 (63.3%) were considered “high volume surgeons”, with more than 100 knee implants per year. Postero-stabilized total knee arthroplasty was the most commonly used, implanted with a fully cemented technique by 162 (91.5%) surgeons. Unicompartmental knee arthroplasty (UKA) was a rarer procedure compared to TKA, with 77% of surgeons performing less than 30% of UKAs. Most common TKA pre-operative radiological planning included complete antero-posterior (AP) weight-bearing lower limb radiographs, lateral view and patellofemoral view (used by 91%, 98.9% and 70.6% of surgeons, respectively). Pre-operative UKA radiological images included Rosenberg or Schuss views, patellofemoral view and magnetic resonance imaging (66.1%, 71.8% and 46.3% of surgeons, respectively). One hundred and thirty-two surgeons (74.6%) included an AP weight-bearing lower limb X-ray one year after surgery in the post-operative radiological follow-up. Furthermore, 119 surgeons (67.2%) did not perform a post-operative patellofemoral view because it was not considered useful for radiological follow-up. There was no uniformity in the timing and features of post-operative follow-up, with 13 different combinations. Conclusions: Italian surgeons perform TKA more commonly than UKA. Pre-operative TKA planning is quite uniform rather than UKA planning. Despite literature evidence, there is no agreement on follow-up. It may be useful to create a uniform checklist, including correct timing and exams needed. This analysis is also part of a society surgical educational project for training doctor.

The role of routine laboratory tests after unilateral total knee arthroplasty

Background

Recent studies suggest that routine laboratory tests are not required within 1 day after partial knee arthroplasty. In this study, we evaluated the utility of routine postoperative laboratory tests after initial unilateral total knee arthroplasty (TKA) in an Asian population. In addition, we explored risk factors associated with abnormal test results.

Methods

Clinical data of patients who underwent original unilateral TKA between 2015 and 2020 were retrospectively analyzed. Patient characteristics and laboratory test results were recorded. Multivariate binary logistic regression analysis was performed to identify risk factors associated with 3 abnormal laboratory results.

Results

A total of 713 patients, who underwent relevant laboratory tests within 3 days of TKA surgery, were enrolled. Among them, 8.1%, 9.9%, and 3.4% patients with anemia, hypoalbuminemia, and abnormal serum potassium levels required clinical intervention after surgery. Binary logistic regression analysis revealed that preoperative hemoglobin levels, estimated blood loss, and age were independent risk factors of postoperative blood transfusion in TKA patients. On the other hand, preoperative albumin levels, intraoperative blood loss, and operation time were risk factors associated with postoperative albumin supplementation. In addition, lower body mass index (BMI) and preoperative hypokalemia were potential risk factors of postoperative potassium supplementation.

Conclusion

Considering that more than 90% of abnormal postoperative laboratory tests do not require clinical intervention, we believe that routine laboratory tests after surgery have little significance in patients with primary unilateral TKA. However, postoperative laboratory testing is necessary for patients with established risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05509-0.

No effect of fixation type on early and late mortality after total knee arthroplasty: a Dutch arthroplasty register study

PURPOSE

Postoperative mortality is commonly reported as outcome measurement after total knee arthroplasty (TKA). Mortality might be influenced by multiple factors including cementation of the prosthesis. Until now, the influence of cementation on early and late mortality after TKA is unknown. The aim of the present study was to determine the effect of fixation on early and late mortality after primary TKA.

METHODS

All patients in the Dutch Arthroplasty Register (LROI) with a primary TKA for osteoarthritis were eligible for inclusion. Data collected from 2007 to 2014 with follow-up until January 2020 were used. Survival analysis was performed by using Kaplan-Meier and Cox survival analysis to determine the mortality rate according to fixation. Adjustments were made for age at time of surgery, gender, American Society of Anaesthesiologists class, and year of surgery.

RESULTS

In total 108,687 TKA were included for analysis, which comprised 95,857 cemented, 6,140 cementless and 6,690 hybrid TKA. The early and late mortality rate in cemented TKA was statistically not different compared to cementless or hybrid TKA at 30 days, 31-90 days, 91 days-1 year and 1-5 years. The hazard ratio at 30 days was 1.05 (CI 0.49-2.25) for hybrid fixation, and 1.46 (CI 0.74-2.90) for cementless fixation compared to cemented fixation. The 1-5 years hazard ratio was 1.06 (CI 0.96-1.17) and 0.97 (CI 0.87-1.08), respectively.

CONCLUSION

Based on register data, method of fixation does not influence early mortality after primary TKA. This suggests that there is no preferred fixation technique for primary TKA based on the mortality rates.

LEVEL OF EVIDENCE

IV.

Cemented Versus Noncemented Total Knee Arthroplasty Outcomes

INTRODUCTION

Aseptic loosening remains one of the most common indications for revision total knee arthroplasty (TKA). Given the demographic shift to a younger and more active TKA patient population, some surgeons have revisited noncemented fixation given its potential for lower rates of long-term aseptic loosening. The purpose of this study was to compare the demographics and complications between patients undergoing noncemented and cemented TKA.

METHODS

Using the MKnee subset of the PearlDiver database, diagnosis and procedure codes were used to identify patients who had undergone cemented or noncemented TKA for osteoarthritis with a minimum 2-year follow-up. Propensity score matching was done to compare risk-adjusted medical and surgical complication profiles at 90 days, 1 year, and 2 years.

RESULTS

Of 203,574 patients identified, 3.2% underwent noncemented TKA and 96.8% underwent cemented TKA. Using propensity-matched analysis, there was no difference in 90-day medical complications. Noncemented TKA was associated with a greater risk of periprosthetic joint infection throughout the study (90-day odds ratio [OR] 1.34, 1-year OR 1.27, 2-year OR 1.27, P < 0.05). Noncemented TKA was associated with a greater risk of periprosthetic fracture at 1 year and 2 years (1 year OR 2.19, 2 years OR 1.89, P < 0.05). No notable difference was observed in risk of aseptic loosening between the two groups.

DISCUSSION

Noncemented TKA is associated with a higher rate of periprosthetic joint infection and periprosthetic fracture. Additional studies are needed to compare long-term rates of aseptic loosening between noncemented and cemented TKA.

LEVEL OF EVIDENCE

Level III.

Pulsatile Lavage During Cementation of Total Knee Arthroplasty - Is Fixation Impaired? A Cadaver Study

BACKGROUND/AIM

Increasing economic pressure in modern healthcare necessitates an increase in efficiency in total knee arthroplasty (TKA) while maintaining high-quality outcomes. Removal of debris using pulsatile lavage (PL) during cement polymerization may considerably reduce the operative duration. However, water can penetrate the interface, resulting in impaired implant fixation. The aim of the present study was to investigate the impact of early-onset PL during bone cement polymerization on implant fixation and operative duration.

MATERIALS AND METHODS

Cemented implantation of tibial trays was performed in 20 fresh-frozen human tibiae from 10 donors in a matched-pair study design in two groups: 1) PL during cement polymerization; and 2) PL after completion of the polymerization process. The cement penetration depth was analysed by computed tomography (CT), and the pull-out force was measured to evaluate primary implant fixation. The duration of the procedure was recorded for both groups.

RESULTS

Comparable pull-out forces were observed in the experimental (2,213 N) and control groups (2,350 N; p=0.68). The mean depth of cement penetration was similar in both groups. PL during cement polymerization could decrease the operative duration by 10 min.

CONCLUSION

The application of PL during cement polymerization could significantly reduce operative duration and had no adverse effect on the mechanical fixation of the tibial component.

Sport after Knee Replacement Surgery - a Review of Sport Habits and Key Surgical Aspects

As an increasing number of younger patients are undergoing total knee replacement (TKR) surgery, many wish to participate in sport, but still expect that the implant will survive for a extended period. Most of the current literature shows that patients predominantly participate in low impact activities, both before and after surgery. A few studies show that with appropriate previous experience, high-impact sports are possible and might not result in increased implant failure rates. These include a decrease in point loads on the polyethylene by using more conform bearing surfaces, avoidance of varus component alignment to minimise stresses at the implant bone interface and avoiding patella resurfacing to facilitate activities in deep knee flexion.A TKR is no longer an absolute contraindication for higher impact activities such as golf, tennis and ski. What is more important than implant specific factors seem to be patient specific factors, including preoperative activity level, and preoperative sport skills.The current review paper reports on the current sport habits of TKR patients, analyses biomechanical loads on the knee during different sport activities and reports on implant selection and technical considerations for the active patient undergoing TKR.

Enhanced osseointegration through direct energy deposition porous coating for cementless orthopedic implant fixation

Direct energy deposition (DED) is a newly developed 3D metal printing technique that can be utilized on a porous surface coating of joint implants, however there is still a lack of studies on what advantages DED has over conventional techniques. We conducted a systematic mechanical and biological comparative study of porous coatings prepared using the DED method and other commercially available technologies including titanium plasma spray (TPS), and powder bed fusion (PBF). DED showed higher porosity surface (48.54%) than TPS (21.4%) and PBF (35.91%) with comparable fatigue cycle. At initial cell adhesion, cells on DED and PBF surface appeared to spread well with distinct actin stress fibers through immunofluorescence study. It means that the osteoblasts bind more strongly to the DED and PBF surface. Also, DED surface showed higher cell proliferation (1.27 times higher than TPS and PBF) and osteoblast cell activity (1.28 times higher than PBF) for 2 weeks culture in vitro test. In addition, DED surface showed better bone to implant contact and new bone formation than TPS in in vivo study. DED surface also showed consistently good osseointegration performance throughout the early and late period of osseointegration. Collectively, these results show that the DED coating method is an innovative technology that can be utilized to make cementless joint implants.

Preliminary clinical results of coated porous tibia cones in septic and aseptic revision knee arthroplasty

PURPOSE

To analyze the first results of calcium-phosphate-coated porous tibia cones.

METHODS

Patients treated with TrabecuLink^®-CaP Cones were retrospectively recruited from January 2016 to December 2017. These custom-made cones were produced using titanium alloy Ti-6Al-4 V (Tilastan^®) and using additive manufacturing with a special calcium-phosphate coating (HX^®-coating). Clinical outcome was evaluated using Oxford Knee Score. For radiological evaluation of the implants, patients sent us outpatient taken radiographs. A minimum follow-up of one year was required. Lastly, we analyzed postoperative complications and revision rates.

RESULTS

52 patients with revision knee arthroplasty (RKA) were recruited for final analysis, of whom, we had 17 septic RKAs (33%) and 35 aseptic cases of RKA (67%). The bone defects were grouped into 17 AORI Type 2A (32.7%), 14 Type 2B (26.9%) and 21 Type 3 (40.4%). After a mean follow-up of 22 months (13.2-34.8; SD = ± 10), we had 4 surgical revisions (7.7%), 2 septic and 2 aseptic cases. The mean Oxford Knee Score was 28.6 points (8-47; SD = ± 10). 22 of 28 radiographs (78.6%) showed regular positioning of the cones and TKAs at a mean follow-up of 16.8 months (13.2-34.8; SD = ± 6). Three patients (10.7%) showed slight radiolucencies in the bone-cement interfaces and 3 patients (10.7%) had beginning heterotopic ossifications.

CONCLUSIONS

This study shows the initial clinical results of calcium-phosphate-coated tibia cones showing a good functional outcome. Further research should focus on long-term clinical and radiological follow-up.