Aims. The primary objective of this registry-based study was to compare patient-reported outcomes of cementless and cemented medial unicompartmental knee arthroplasty (UKA) during the first postoperative year. The secondary objective was to assess one- and three-year implant survival of both fixation techniques. Methods. We analyzed 10,862 cementless and 7,917 cemented UKA cases enrolled in the Dutch Arthroplasty Registry, operated between 2017 and 2021. Pre- to postoperative change in outcomes at six and 12 months’ follow-up were compared using mixed model analyses. Kaplan-Meier and Cox regression models were applied to quantify differences in implant survival. Adjustments were made for patient-specific variables and annual hospital volume. Results. Change from baseline in the Oxford Knee Score (OKS) and activity-related pain was comparable between groups. Adjustment for covariates demonstrated a minimally greater decrease in rest-related pain in the cemented group (β = -0.09 (95% confidence interval (CI) -0.16 to -0.01)). Cementless fixation was associated with a higher probability of achieving an excellent OKS outcome (> 41 points) (adjusted odds ratio 1.2 (95% CI 1.1 to 1.3)). The likelihood of one-year implant survival was greater for cemented implants (adjusted hazard ratio (HR) 1.35 (95% CI 1.01 to 1.71)), with higher revision rates for periprosthetic fractures of cementless implants. During two to three years’ follow-up, the likelihood of implant survival was non-significantly greater for cementless UKA (adjusted HR 0.64 (95% CI 0.40 to 1.04)), primarily due to increased revision rates for tibial loosening of cemented implants. Conclusion. Cementless and cemented medial UKA led to comparable improvement in physical function and pain reduction during the initial postoperative year, albeit with a greater likelihood of achieving excellent OKS outcomes after cementless UKA. Anticipated differences in early physical function and pain should not be a decisive factor in the choice of fixation technique. However, surgeons should consider the differences in short- and long-term implant survival when deciding which implant to use. Cite this article: Bone Jt Open 2024;5(5):401–410

The Cementless Oxford Unicompartmental Knee Replacement (OUKR) was developed to address problems related to cementation, and has been demonstrated in a randomised study to have similar clinical outcomes with fewer radiolucencies than observed with the cemented device. However, before its widespread use it is necessary to clarify contraindications and assess the complications. This requires a larger study than any previously published. We present a prospective multicentre series of 1000 cementless OUKRs in 881 patients at a minimum follow-up of one year. All patients had radiological assessment aligned to the bone–implant interfaces and clinical scores. Analysis was performed at a mean of 38.2 months (19 to 88) following surgery. A total of 17 patients died (comprising 19 knees (1.9%)), none as a result of surgery; there were no tibial or femoral loosenings. A total of 19 knees (1.9%) had significant implant-related complications or required revision. Implant survival at six years was 97.2%, and there was a partial radiolucency at the bone–implant interface in 72 knees (8.9%), with no complete radiolucencies. There was no significant increase in complication rate compared with cemented fixation (p = 0.87), and no specific contraindications to cementless fixation were identified. Cementless OUKR appears to be safe and reproducible in patients with end-stage anteromedial osteoarthritis of the knee, with radiological evidence of improved fixation compared with previous reports using cemented fixation. Cite this article: Bone Joint J 2013;95-B:181–7

There has been a recent increase in interest for non-cemented fixation in total knee arthroplasty (TKA), however the superiority of cement fixation is an ongoing debate.

Whereas the results based on Level III and IV evidence show similar survivorship rates between the two types of fixation, Level I and II evidence strongly support cemented fixation. United Kingdom, Australia, Sweden, and New Zealand registry data show lower failure rates and greater usage of cemented than non-cemented fixation. Case series studies have also indicated greater functional outcomes and lower revision rates among cemented TKAs. Non-cemented fixation involves more patellofemoral complications, including increased susceptibility to wear due to a thinner polyethylene bearing on the cementless metal-backed component. The combination of results from registry data, prospective randomised studies, and meta-analyses support the current superiority of cemented fixation in TKAs.

In this study we present our experience with four generations of uncemented total knee arthroplasty (TKA) from Smith & Nephew: Tricon M, Tricon LS, Tricon II and Profix, focusing on the failure rates correlating with each design change. Beginning in 1984, 380 Tricon M, 435 Tricon LS, 305 Tricon 2 and 588 Profix were implanted by the senior author. The rate of revision for loosening was 1.1% for the Tricon M, 1.1% for the Tricon LS, 0.5% for the Tricon 2 with a HA coated tibial component, and 1.3% for the Profix TKA. No loosening of the femoral component was seen with the Tricon M, Tricon LS or Tricon 2, with no loosening seen of the tibial component with the Profix TKA. Regarding revision for wear, the incidence was 13.1% for the Tricon M, 6.6% for the Tricon LS, 2.3% for the Tricon 2, and 0% for the Profix. These results demonstrate that improvements in the design of uncemented components, including increased polyethylene thickness, improved polyethylene quality, and the introduction of hydroxyapatite coating, has improved the outcomes of uncemented TKA over time.

Cementless knee arthroplasty has seen a recent resurgence in popularity due to conceptual advantages, including improved osseointegration providing biological fixation, increased surgical efficiency, and reduced systemic complications associated with cement impaction and wear from cement debris. Increasingly younger and higher demand patients are requiring knee arthroplasty, and as such, there is optimism cementless fixation may improve implant survivorship and functional outcomes. Compared to cemented implants, the National Joint Registry (NJR) currently reports higher revision rates in cementless total knee arthroplasty (TKA), but lower in unicompartmental knee arthroplasty (UKA). However, recent studies are beginning to show excellent outcomes with cementless implants, particularly with UKA which has shown superior performance to cemented varieties. Cementless TKA has yet to show long-term benefit, and currently performs equivalently to cemented in short- to medium-term cohort studies. However, with novel concepts including 3D-printed coatings, robotic-assisted surgery, radiostereometric analysis, and kinematic or functional knee alignment principles, it is hoped they may help improve the outcomes of cementless TKA in the long-term. In addition, though cementless implant costs remain higher due to novel implant coatings, it is speculated cost-effectiveness can be achieved through greater surgical efficiency and potential reduction in revision costs. There is paucity of level one data on long-term outcomes between fixation methods and the cost-effectiveness of modern cementless knee arthroplasty. This review explores recent literature on cementless knee arthroplasty, with regards to clinical outcomes, implant survivorship, complications, and cost-effectiveness; providing a concise update to assist clinicians on implant choice. Cite this article: Bone Jt Open 2021;2(1):48–57

Aims. Cementless total knee arthroplasty (TKA) offers the potential for strong biological fixation compared with cemented TKA where fixation is achieved by the mechanical integration of the cement. Few mid-term results are available for newer cementless TKA designs, which have used additive manufacturing (3D printing). The aim of this study was to present mid-term clinical outcomes and implant survivorship of the cementless Stryker Triathlon Tritanium TKA. Methods. This was a single institution registry review of prospectively gathered data from 341 cementless Triathlon Tritanium TKAs at four to 6.8 years follow-up. Outcomes were determined by comparing pre- and postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) scores, and pre- and postoperative 12-item Veterans RAND/Short Form Health Survey (VR/SF-12) scores. Aseptic loosening and revision for any reason were the endpoints which were used to determine survivorship at five years. Results. At mid-term follow-up, the mean KOOS JR score improved significantly from 33.14 (0 t0 85, standard deviation (SD) 21.88) preoperatively to 84.12 (15.94 to 100, SD 20.51) postoperatively (p < 0.001), the mean VR/SF-12 scores improved significantly from physical health (PH), 31.21 (SD 5.32; 23.99 to 56.77) preoperatively to 42.62 (SD 10.72; 19.38 to 56.82) postoperatively (p < 0.001) and the mental health (MH), 38.15 (SD 8.17; 19.06 to 60.75) preoperatively to 55.09 (SD 9.64; 19.06 to 66.98) postoperatively (p < 0.001). A total of 11 revisions were undertaken, with an overall revision rate of 2.94%, including five for periprosthetic joint infection (1.34%), three for loosening (0.80%), two for instability (0.53%), and one for pain (0.27%). The overall survivorship was 97.06% and survivorship for aseptic loosening as the endpoint was 98.40%, with a 99.5% survivorship of the 3D-printed tibial component. Conclusion. This 3D-printed cementless total knee system shows excellent survivorship at mid-term follow-up. This design and the ability to obtain cementless fixation offers promise for excellent long-term durability. Cite this article: Bone Joint J 2021;103-B(6 Supple A):32–37

Aims. Cementless unicompartmental knee arthroplasty (UKA) has advantages over cemented UKA, including improved fixation, but has a higher risk of tibial plateau fracture, particularly in Japanese patients. The aim of this multicentre study was to determine when cementless tibial components could safely be used in Japanese patients based on the size and shape of the tibia. Methods. The study involved 212 cementless Oxford UKAs which were undertaken in 174 patients in six hospitals. The medial eminence line (MEL), which is a line parallel to the tibial axis passing through the tip of medial intercondylar eminence, was drawn on preoperative radiographs. Knees were classified as having a very overhanging medial tibial condyle if this line passed medial to the medial tibial cortex. They were also classified as very small if a size A/AA tibial component was used. Results. The overall rate of fracture was 8% (17 out of 212 knees). The rate was higher in knees with very overhanging condyles (Odds ratio (OR) 13; p < 0.001) and with very small components (OR 7; p < 0.001). The OR was 21 (p < 0.001) in those with both very overhanging condyles and very small components. In all, 69% of knees (147) had neither very overhanging nor very small components, and the fracture rate in these patients was 1.4% (2 out of 147 knees). Males had a significantly reduced risk of fracture (OR 0.13; p = 0.002), probably because no males required very small components and females were more likely to have very overhanging condyles (OR 3; p = 0.013). 31% of knees (66) were in males and in these the rate of fracture was 1.5% (1 out of 66 knees). Conclusion. The rate of tibial plateau fracture in Japanese patients undergoing cementless UKA is high. We recommend that cemented tibial fixation should be used in Japanese patients who require very small components or have very overhanging condyles, as identified from preoperative radiographs. In the remaining 69% of knees cementless fixation can be used. This approach should result in a low rate of fracture. Cite this article: Bone Joint J 2020;102-B(7):861–867

Aims. Although bone cement is the primary mode of fixation in total knee arthroplasty (TKA), cementless fixation is gaining interest as it has the potential of achieving lasting biological fixation. By 3D printing an implant, highly porous structures can be manufactured, promoting osseointegration into the implant to prevent aseptic loosening. This study compares the migration of cementless, 3D-printed TKA to cemented TKA of a similar design up to two years of follow-up using radiostereometric analysis (RSA) known for its ability to predict aseptic loosening. Methods. A total of 72 patients were randomized to either cementless 3D-printed or a cemented cruciate retaining TKA. RSA and clinical scores were evaluated at baseline and postoperatively at three, 12, and 24 months. A mixed model was used to analyze the repeated measurements. Results. The mean maximum total point motion (MTPM) at three, 12, and 24 months was 0.33 mm (95% confidence interval (CI) 0.25 to 0.42), 0.42 mm (95% CI 0.33 to 0.51), and 0.47 mm (95% CI 0.38 to 0.57) respectively in the cemented group, versus 0.52 mm (95% CI 0.43 to 0.63), 0.62 mm (95% CI 0.52 to 0.73), and 0.64 mm (95% CI 0.53 to 0.75) in the cementless group (p = 0.003). However, using three months as baseline, no difference in mean migration between groups was found (p = 0.497). Three implants in the cemented group showed a > 0.2 mm increase in MTPM between one and two years of follow-up. In the cementless group, one implant was revised due to pain and progressive migration, and one patient had a liner-exchange due to a deep infection. Conclusion. The cementless TKA migrated more than the cemented TKA in the first two-year period. This difference was mainly due to a higher initial migration of the cementless TKA in the first three postoperative months after which stabilization was observed in all but one malaligned and early revised TKA. Whether the biological fixation of the cementless implants will result in an increased long-term survivorship requires a longer follow-up. Cite this article: Bone Joint J 2020;102-B(8):1016–1024

Aims. Early implant migration measured with radiostereometric analysis (RSA) has been proposed as a useful predictor of long-term fixation of tibial components in total knee arthroplasty. Evaluation of actual long-term fixation is of interest for cemented components, as well as for cementless fixation, which may offer long-term advantages once osseointegration has occurred. The objective of this study was to compare the long-term migration with one- and two-year migration to evaluate the predictive ability of short-term migration data and to compare migration and inducible displacement between cemented and cementless (porous metal monoblock) components at least ten years postoperatively. Patients and Methods. Patients who had participated in RSA migration studies with two-year follow-up were recruited to return for a long-term follow-up, at least ten years from surgery. Two cemented tibial designs from two manufacturers and one porous metal monoblock cementless tibial design were studied. At the long-term follow-up, patients had supine RSA examinations to determine migration and loaded examinations (single leg stance) to determine inducible displacement. In total, 79 patients (54 female) returned, with mean time since surgery of 12 years (10 to 14). There were 58 cemented and 21 cementless tibial components. Results. Migration at one year and two years was significantly correlated with long-term migration (p < 0.001). Median migration at the long-term follow-up was 0.6 mm (maximum total point motion; interquartile range (IQR) 0.4 to 0.9) for the cemented group and 0.6 mm. (IQR 0.3 to 1.1) for the cementless group with no difference between groups (p = 0.99). Inducible displacement was significantly lower for the cementless components (p < 0.001). Conclusion. Long-term migration was strongly correlated with two-year migration. Although long-term migration was not different for cemented or cementless tibial components, inducible displacement at the long-term visit was significantly lower for these cementless components, suggesting superior fixation. These findings support the predictive value of short-term migration in determining long-term fixation. Cite this article: Bone Joint J 2019;101-B(7 Supple C):55–60

Aims

The aim of this study was to describe the pattern of revision indications for unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) and any change to this pattern for UKA patients over the last 20 years, and to investigate potential associations to changes in surgical practice over time.

Early implants for total knee replacement were fixed to bone with cement. No firm scientific reason has been given for the introduction of cementless knee replacement and the long-term survivorship of such implants has not shown any advantage over cemented forms. In a randomised, prospective study we have compared cemented and uncemented total knee replacement and report the results of 139 prostheses at five years. Outcome was assessed both clinically by independent examination using the Nottingham knee score and radiologically using the Knee Society scoring system. Independent statistical analysis of the data showed no significant difference between cemented and cementless fixation for pain, mobility or movement. There was no difference in the radiological alignment at five years, but there was a notable disparity in the radiolucent line score. With cemented fixation there was a significantly greater number of radiolucent lines on anteroposterior radiographs of the tibia and lateral radiographs of the femur. At five years, our clinical results would not support the use of the more expensive cementless fixation whereas the radiological results are of unknown significance. Longer follow-up will determine any changes in the results and conclusions

Aims

The mean age of patients undergoing total knee arthroplasty (TKA) has reduced with time. Younger patients have increased expectations following TKA. Aseptic loosening of the tibial component is the most common cause of failure of TKA in the UK. Interest in cementless TKA has re-emerged due to its encouraging results in the younger patient population. We review a large series of tantalum trabecular metal cementless implants in patients who are at the highest risk of revision surgery.

Aims

The primary aim of this study was to compare the migration of the femoral and tibial components of the cementless rotating platform Attune and Low Contact Stress (LCS) total knee arthroplasty (TKA) designs, two years postoperatively, using radiostereometric analysis (RSA) in order to assess the risk of the development of aseptic loosening. A secondary aim was to compare clinical and patient-reported outcome measures (PROMs) between the designs.

Aims

Higher osteoblastic bone activity is expected in aseptic loosening and painful unicompartmental knee arthroplasty (UKA). However, insights into normal bone activity patterns after medial UKAs are lacking. The aim of this study was to identify the evolution in bone activity pattern in well-functioning medial mobile-bearing UKAs.

Metallosis is a rare cause of failure after total knee replacement and has only previously been reported when there has been abnormal metal-on-metal contact. We describe 14 patients (15 knees) whose total knee replacement required revision for a new type of early failure caused by extensive metallosis. A modification of a cementless rotating platform implant, which had previously had excellent long-term survival, had been used in each case. The change was in the form of a new porous-beaded surface on the femoral component to induce cementless fixation, which had been used successfully in the fixation of acetabular and tibial components. This modification appeared to have resulted in metallosis due to abrasive two-body wear. The component has subsequently been recalled and is no longer in use. The presentation, investigation, and findings at revision are described and a possible aetiology and its implications are discussed

Aims

Periprosthetic joint infection (PJI) occurs in approximately 1% to 2% of total knee arthroplasties (TKA) presenting multiple challenges, such as difficulty in diagnosis, technical complexity, and financial costs. Two-stage exchange is the gold standard for treating PJI but emerging evidence suggests 'two-in-one' single-stage revision as an alternative, delivering comparable outcomes, reduced morbidity, and cost-effectiveness. This study investigates five-year results of modified single-stage revision for treatment of PJI following TKA with bone loss.

We have carried out a long-term survival analysis of a prospective, randomised trail comparing cemented with cementless fixation of press-fit condylar primary total knee replacements. A consecutive series of 501 replacements received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. The patients were contacted at a mean follow-up of 7.4 years (2.7 to 13.0) to establish the rate of survival of the implant. The ten-year survival was compared using life-table and Cox’s proportional hazard analysis. No patient was lost to follow-up. The survival at ten years was 95.3% (95% CI 90.3 to 97.8) and 95.6% (95% CI 89.5 to 98.2) in the cemented and cementless groups, respectively. The hazard ratio for failure in cemented compared with cementless prostheses was 0.97 (95% CI 0.36 to 2.6). A comparison of the clinical outcome at ten years in 80 knees showed no difference between the two groups. The survival of the press-fit condylar total knee replacement at ten years is good irrespective of the method of fixation and brings into question the use of more expensive cementless implants

Aims

Our intention was to investigate if the highly porous biological fixation surfaces of a new 3D-printed total knee arthroplasty (TKA) achieved adequate fixation of the tibial and patellar components to the underlying bone.

Aims

The treatment of patients with allergies to metal in total joint arthroplasty is an ongoing debate. Possibilities include the use of hypoallergenic prostheses, as well as the use of standard cobalt-chromium (CoCr) alloy. This non-designer study was performed to evaluate the clinical outcome and survival rates of unicondylar knee arthroplasty (UKA) using a standard CoCr alloy in patients reporting signs of a hypersensitivity to metal.

Objectives

The primary stability of the cementless Oxford Unicompartmental Knee Replacement (OUKR) relies on interference fit (or press fit). Insufficient interference may cause implant loosening, whilst excessive interference could cause bone damage and fracture.

The aim of this study was to identify the optimal interference fit by measuring the force required to seat the tibial component of the cementless OUKR (push-in force) and the force required to remove the component (pull-out force).