Debating the Merits of Cementless TKA

    Dr. Del Schutte and Dr. John Barrington square off on the issue of cemented versus cementless total knee arthroplasty.

    Cemented fixation is the “gold standard” for total knee arthroplasty (TKA). But should it be?

    The answer depends on who is being asked. John W. Barrington, MD, and H. Del Schutte, MD, have different opinions, and at ICJR’s annual Winter Hip & Knee Course, they debated the issue of cemented versus cementless TKAs.

    Dr. Schutte, from Southern Orthopaedics & Sports Medicine in Charleston, South Carolina, believes orthopaedic surgeons have entered an era in which surgical techniques, materials, and locking mechanisms have improved to the point that cementless primary TKA is a viable and desirable option. In the near future, he said, cementless primary TKA will be the new “gold standard.”

    He quoted a 2013 study by Harwin [1] that included 114 consecutive TKAs using the cementless PS Triathlon PS-PA TKA prostheses. At 36 months of follow-up, none of the knees showed loosening or failure of ingrowth. Conceding this is a relatively short follow-up, Dr. Schutte said the fact remains that once biologic fixation and bony ingrowth are achieved, the components remain very well fixed.

    The cementless technique is also more efficient, Dr. Schutte said. Using cement takes time, and longer surgical time has been shown to be related to higher incidence of infections. Use of cement also requires the surgeon be aware of operating room temperature and humidity for optimal results.

    Cementless TKA is a tourniquet-less technique, and Dr. Schutte noted several advantages to this:

    • Better prosthesis fit with no tibial overhang
    • Eliminates ischemia during the procedure
    • Decreases early postoperative pain and possible nerve injury
    • Improves postoperative muscle function, patellar tracking, and range of motion

    Dr. Schutte’s presentation can be found here.

    Dr. Barrington, from the Texas Joint Replacement Center in Plano, Texas, is not sold on the benefits of cementless TKAs. He cited registry data, randomized controlled trials (RCTs), and meta-analyses showing that outcomes are not better with cementless fixation.

    A 2002 Danish Registry report and a 2012 Swedish Registry Report have revision rates for cementless TKAs are 48% and 60% higher, respectively, than the revision rates for cemented TKAs.

    A 2012 Cochrane meta-analysis of five RCTs comparing cemented and cementless TKAs shows that cemented tibial components migrate significantly less than cementless tibias. This debunks the premise that cementless fixation is going to be more biologic, more durable, and leads to less migration, Dr. Barrington said.

    A meta-analysis of nine RCTs and observational case-control studies comparing cemented and cementless versions of the same modern prosthesis found an Odds Ratio (OR) for aseptic loosening of cementless components of 1.9 for the randomized control trials, and an OR of 4.2 for all the included studies. Even including more modern components using the latest ingrowth-promoting coatings shows increasing OR of 3.41 at 5 years and 4.73 at 10 years.

    Dr. Barrington concluded that currently available Level I evidence from registry data, RCTs, and meta-analyses support the superiority of cemented fixation over cementless fixation in TKAs.

    Dr. Barrington’s presentation can be found here.


    1. Harwin SF, Kester MA, Malkani AL, Manley MT. Excellent fixation achieved with cementless posteriorly stabilized total knee arthroplasty. J Arthroplasty. 2013 Jan;28(1):7-13. doi: 10.1016/j.arth.2012.06.006. Epub 2012 Jul 31.