Hybrid fixation versus full-cemented or full-cementless fixation in total knee arthroplasty: Systematic review and meta-analysis of comparative studies

ObjectiveHybrid fixation is one alternative to full-cemented fixation in total knee arthroplasty (TKA) with theoretical advantages. Hybrid fixation may offer the advantages of cementless femoral fixation, while also avoiding the problem of tibial loosening in full-cementless TKA. The purpose of the study is to determine whether hybrid TKA may perform comparably to or better than full-cemented and full-cementless TKA.MethodsWe searched the MEDLINE, EMBASE and Cochrane Library databases through September 2018 for randomized controlled trials and observational studies comparing outcomes of hybrid versus full-cemented or full-cementless fixation techniques. Outcomes of interest included aseptic loosening, overall reoperation rate, infection, radiolucent lines and operating time. Data were pooled with the Mantel–Haenszel random effects model.ResultsWe included 14 studies with follow-up ranging from 2.7 to 9.6 years in our quantitative analysis, of which 7 studies compared hybrid fixation with full-cemented TKA and another 7 compared hybrid fixation with full-cementless TKA. Combined data revealed that the hybrid fixation group had a similar rate of aseptic loosening compared with cemented (P = 0.19) and cementless (P = 0.49) groups. There was no difference with respect to other outcomes, including overall reoperation rate, infection, radiolucent lines and operating time between groups.ConclusionHybrid, cementless and cemented TKAs have comparable mid-term results as it pertains to aseptic loosening, overall reoperation, infection, radiolucent lines and operating time. Further comparative studies are needed to investigate these potential effects over the long-term.     

Hybrid total knee arthroplasty analysis of component failures at an average of 15 years

Hybrid total knee arthroplasty in which the femoral component is cementless and the tibial component is cemented remains controversial. We report on the long-term results of 65 total knee arthroplasties followed for an average of 15 years. There were 18 revisions (27%); of these, 11 were femoral component revisions. The overall implant survival with revision as the end point was estimated as 64% at 15 years. The femoral component survivorship at 15 years was 72%. Because of the high failure rate, hybrid fixation on the femoral side with this design has been abandoned at our institution; but hybrid fixation with a trabecular metal tibia is currently under investigation.     

Tibial component fixation with a peri-apatite coating: evaluation by radiostereometric analysis in a canine total knee arthroplasty model

Cementless fixation for the tibial component in total knee arthroplasty (TKA) remains problematic. Peri-Apatite (PA), a solution-deposited hydroxyapatite, is under investigation as an option for improving the fixation of cementless tibial components. In this study, radiostereometric analysis was used to document implant migration in 48 dogs that underwent TKA with cementless, PA-coated, or cemented tibial components. Migration at 12 weeks was similar in the 2 groups. At 12 months, there was greater migration in the PA-coated group, but the difference between the 2 groups was below the threshold considered clinically significant. In this canine TKA model, cementless fixation with PA performed less well than did cemented fixation, but not to a degree that would make a clinical difference in the short term.     

Cemented Versus Cementless Fixation of a Tibial Component in LCS Mobile-Bearing Total Knee Arthroplasty Performed by a Single Surgeon

Although cemented tibial fixation of total knee arthroplasty accepted as the gold standard, cementless fixation as a means to supplement disadvantages of cemented fixation continues to be of interest to clinicians. One hundred sixty-eight consecutive knees undergoing primary knee arthroplasty for osteoarthritis were randomly assigned to receive either a cemented (86 knees) or cementless (82 knees) fixation of tibial component. We report the outcomes at 8 to 11 years (mean, 9.5). The mean KSS, the HSS score, the mean WOMAC, the mean ranges of knee movement and radiological results were similar in both groups. No osteolysis was identified in either group. The rate of survival of the femoral and tibial components was 100% in both groups at final follow-up.     

Results of 1,000 performance knees: Cementless versus cemented fixation

A total of 893 patients with 1,000 Performance total knee prostheses were retrospectively studied. The mean follow-up was 5.2 years. In 584 cases, the femoral and tibial components were implanted using cementless techniques, and in 416 knees the femoral and tibial components were cemented. All patients received a cemented all polyethylene patellar replacement. Tibial bone density determined fixation type. The average age of patients with cementless fixation was 64.3 years versus 76.2 years for patients with cemented implants. The average subjective and functional Knee Society scores were 91.2 and 90.1 for patients with cementless knees and 89.6 and 83.5 for those with cemented replacements. A surprising absence of osteolysis around screw fixation was noted, and at 5 years, there was 99% implant survival.     

Hybrid total knee arthroplasty

A prospective study of a hybrid total knee arthroplasty (TKA) with an uncemented femoral component and cemented tibial and patellar components was performed to combine the advantage of a press-fit femur while avoiding the problems in uncemented tibial and patellar implants. A total of 329 posterior cruciate-preserving TKA were studied at an average of 4.7 years after surgery: 84% of the knees had at most mild or occasional pain, 68% had good or excellent knee scores, and 62% could walk more than 1000 m. The function scores were 40% good or excellent in this collective, with an average age of 69.4 years at surgery. The component position and alignment were biomechanically correct. Radiolucent lines were observed regularly at the edges of the tibial and femoral components. There were no revisions for aseptic loosening. Hybrid TKA provides good results comparable to cemented TKA.     

使用与不用骨水泥固定人工膝关节置换术后疗效的比较

探讨使用与不用骨水泥固定氧化铝陶瓷制NCU型TKA术后的疗效。1989～1995年,为了治疗晚期骨性关节病及类风湿病,共施行NCU型TKA68例103个关节。对获得平均随访5年8个月的65例99个关节的以胫骨假体为中心的临床评价及X线计测的结果进行了比较性分析。临床评价方法是以JOA膝关节评价基准为标准,X线的评价方法是将术前、术后、最终调查时的正侧位X线照片数字化后输入电子计算机利用电脑软件系统进行了计测与评价。65例99个关节TKA术后经随访5年以上的结果表明NCU型TKA术后获得了比较良好的疗效。术后并发症7％,再手术率5％,不用骨水泥组疗效劣于使用骨水泥固定组,两组间的疼痛评分及透亮线出现率的差异均有显著性统计学意义。     

Stem fixation in revision total knee arthroplasty: a comparative analysis

Methods of stem fixation are a controversial aspect of revision TKA. We sought to determine which technique was superior by reviewing 475 revision TKAs done between 1986 and 2000. Of these 475 revisions, 286 major component revisions were done using 484 extended stems for fixation. Patients who died, patients who had less than 2 years follow up, or patients who had diaphyseal engaging stems were excluded from the study. The final data set included 113 revision TKAs with 202 metaphyseal engaging stems. Of the 202 stems, 107 were cemented whereas 95 were press-fit metaphyseal engaging stems. One hundred one of these were femoral stems and 101 were tibial stems. Using a modified Knee Society radiographic scoring system, 100 (93%) of the 107 implants with cemented stems were considered stable, seven (7%) were categorized as possibly loose requiring close followup, and none were loose. Of the 95 implants placed with cementless stems, only 67 (71%) were categorized as stable. Eighteen (19%) were possibly loose requiring close followup and 10 (10%) were loose (two tibial and eight femoral implants). We currently would urge caution in using cementless metaphyseal engaging stems for fixation in revision TKA.     

Results of Cemented vs Cementless Primary Total Knee Arthroplasty Using the Same Implant Design

Background

Although cemented total knee arthroplasty (TKA) continues to be the gold standard, there are patient populations with higher failure rates with cemented TKAs such as the obese, morbidly obese, and younger active males. Cementless TKA usage continues to increase because of the potential benefits of long-term biologic fixation similar to the rise in cementless total hip arthroplasty. The purpose of this study was to evaluate the clinical and radiographic results of cementless TKA using a novel highly porous cementless tibial baseplate.

Cementless vs Cemented Tibial Fixation in Primary Total Knee Arthroplasty

Background

The ideal fixation for modern tibial components in total knee arthroplasty (TKA) remains controversial with uncertainty on whether cementless implants can yield equivalent outcomes to cemented fixation in early follow-up.

骨水泥与非骨水泥固定在初次全膝关节置换术中的应用:系统评价和meta分析

背景:全膝关节置换术(TKA)治疗终末期膝关节疾病的效果已被公认。目前TKA中假体-骨的固定形式主要有骨水泥固定和非骨水泥固定两种;前者应用广泛,但理想的假体固定方法仍存在争议。目的:通过meta分析评价骨水泥或非骨水泥固定在初次TKA中的优缺点,探讨其不同的适应证并提出TKA的最佳固定方式。方法:通过检索策略检索PubMed、The Cochrane Library、EMbase、CNKI、VIP、CBM和万方数据库,收集所有TKA术中骨水泥和非骨水泥固定的报道,采用RevMan 5.1软件进行meta分析。结果:最终纳入17项研究,并对其报道的结局指标进行合并分析。其中9项研究报道了TKA术后5年内的膝关节假体生存率,发现骨水泥固定组与非骨水泥固定组间生存率有显著统计学差异(RR=1.02,95%CI:1.00~1.05,P=0.02),但5年后的膝关节假体生存率无统计学差异(RR=1.01,95%CI:0.97~1.04,P=0.75)。术后假体相关并发症,骨水泥与非骨水泥固定组间无显著统计学差异(RR=0.97,95%CI:0.75~1.27,P=0.84)。影像学指标:术后两组间胫骨组件位置在冠状位及矢状位上偏移度数存在统计学差异,其他指标无统计学意义。结论:非骨水泥固定TKA植入组件发生偏转的概率相对较高,但非骨水泥固定TKA在假体中期生存率和临床疗效方面与骨水泥固定结果相似。为了更全面、准确地评价骨水泥固定与非骨水泥固定的长期生存率、安全性、临床及放射学指标,还需进一步研究。     

Cemented and ingrowth fixation of the Miller-Galante prosthesis. Clinical and roentgenographic comparison after three- to six-year follow-up studies

One hundred thirty-nine cemented and 132 cementless Miller-Galante total knee prostheses were followed between three and six years (average, 43-44 months). The fixation technique was based on patient age, bone quality, and ability to delay full-weight bearing. Clinical follow-up studies were possible on 116 cemented knees. Fifteen knees were lost because of death before the three-year follow-up study, and eight knees required component removal. One hundred twenty-three cementless knees were available for clinical follow-up studies; there were three deaths, and six failures required component removal. No cemented failure was due to fixation, and three cementless failures were due to lack of tibial ingrowth in two and pain of undetermined etiology in one. Preoperative knee scores were slightly significant with cemented knees averaging 48 points and cementless knees averaging 52 points. A similar significant difference was maintained at the final follow-up study. No significant differences were noted for pain, limp, or support scores. Average range of motion was similar in the two groups. Radiolucent lines about the femoral component were rare. Cementless tibial radiolucencies were partial in up to 20% of examined zones, and complete tibial tray radiolucency was seen in only three patients. No correlation between radiolucency and knee scores was seen.     

Increased Survivorship of Cementless versus Cemented TKA in the Morbidly Obese. A Minimum 5-Year Follow-Up

Background

Total knee arthroplasty (TKA) in the morbidly obese patients can be challenging with an increased risk of complications. Studies have shown increased aseptic failures with well-aligned cemented TKAs in the obese patient. The purpose of this study is to determine if TKA in the morbidly obese (body mass index [BMI] ≥ 40) using cementless implants would demonstrate improved results and survivorship compared to cemented TKA at a minimum 5-year follow-up.

Average 10.1-year follow-up of cementless total knee arthroplasty in patients with rheumatoid arthritis

Background

Total knee arthroplasty (TKA) using a cemented technique has been recommended in patients with rheumatoid arthritis owing to the initial stability of the fixation and long-term durability of the components; however, similar long-term follow-up results have been reported in patients who have undergone cementless TKA. The purpose of this study was to evaluate the radiologic and clinical outcomes of cementless TKA in patients with rheumatoid arthritis.

Methods

We enrolled patients undergoing cementless TKA from March 1990 to February 2000. Clinical and radiologic evaluations were performed using the Knee Society clinical rating system and radiographic evaluation and scoring system.

Results

We included the cases of 112 patients who underwent 179 cementless TKA procedures in our analysis. Their mean age was 62.3 years, and the mean follow-up period was 10.1 years. The final survival rate was 0.968 at the 15.5-year follow-up. Regarding radiologic results after surgery, the mean total valgus angle was 6.7°, the mean femoral flexion angle was 97.5° and the mean tibial angle was 89.2° on the anteroposterior radiographs. On the lateral films, the mean femoral flexion angle was 1.6° and the mean tibial angle was 89.2°. At the last follow-up, the mean total valgus angle was 6.5°, the mean femoral flexion angle was 97.4° and the mean tibial angle was 89.1°, as seen on the anteroposterior view. On the lateral views, the mean femoral flexion angle was 1.4° and the mean tibial angle was 89.0°. Regarding the clinical outcome, the mean knee score and function score on the Knee Society clinical rating system were also enhanced from 47.5 and 43.6, respectively, before the operation to 91.2 and 82.3, respectively, at the last follow-up.

Conclusion

On radiologic and clinical follow-up of cementless TKA for patients with rheumatoid arthritis, there were no serious complications, and the results of the operation were satisfactory with improvement in range of motion and clinical symptoms.     

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

BackgroundCementless 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.MethodsA 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.ResultsMUA-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).ConclusionEarly 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.     

Hydroxyapatite-coated tibial implants compared with cemented tibial fixation in primary total knee arthroplasty. A randomized trial of outcomes at five years

BACKGROUND: Although excellent long-term results have been reported with cemented tibial fixation, cementless fixation as a means to improve the longevity of total knee prostheses continues to be of interest to clinicians. The purpose of this study was to compare outcomes between cementless tibial fixation with hydroxyapatite and cemented tibial fixation in the first five years following primary total knee arthroplasty. METHODS: We performed a prospective, randomized clinical trial that included eighty-one patients with noninflammatory knee arthritis who underwent primary total knee arthroplasty when they were less than seventy years of age. The subjects were randomized at the time of surgery to be treated with either cementless tibial fixation with hydroxyapatite or cemented tibial fixation. Evaluations were performed preoperatively and at six months, one year, and five years postoperatively by a physical therapist who was blinded to group allocation. Self-reported pain and function, the primary outcomes, were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the RAND 36-Item Health Survey (RAND-36). Complications and revision rates were determined through a review of hospital records and at each patient evaluation. The Knee Society radiographic score was used to evaluate plain radiographs at each assessment. RESULTS: Seventy subjects (86%) completed the five-year assessment. Slightly more pain was reported in the hydroxyapatite group at six months as measured with both the WOMAC and the RAND-36, a difference that disappeared by one year postoperatively. No differences were seen in function, radiographic findings, or complications. No subject required revision of the tibial prosthesis during the study. CONCLUSIONS: At five years postoperatively, there is no difference between cementless tibial fixation with hydroxyapatite and cemented tibial fixation in terms of self-reported pain, function, health-related quality of life, postoperative complications, or radiographic scores.     

Total knee arthroplasty. Two- to four-year experience using an asymmetric tibial tray and a deep trochlear-grooved femoral component

The design features of an implant system can be crucial to the success of cementless total knee arthroplasty (TKA). The implant system described in this study incorporates anatomic features including an asymmetric tibial tray that is smaller laterally than medially, and a deep trochlear-grooved femoral component. Two hundred consecutive primary total knees were implanted between October 18, 1985 and January 19, 1988 and were followed prospectively. One hundred ninety-two were implanted without cement. Clinical evaluation demonstrates good or excellent results in 96%, including a mean range of motion of 122 at two to four years after arthroplasty. Routine fluoroscopic spot roentgenograms have shown no complete radiolucency in this series of patients. Bone ingrowth was predictable if morselized autograft bone was interposed between implant and host bone. Implant retrievals demonstrated uniform bone ingrowth into the porous coating, increasing to 40% of the pore volume in the tibial tray at 27 months. Restoration of the normal kinematics appears to minimize the bone-implant stress permitting bone ingrowth fixation. The results of primary cementless TKA in this series is comparable to cemented TKA with the advantage of conserving bone stock.     

Survivorship of Metaphyseal Sleeves in Revision Total Knee Arthroplasty

Background

Metaphyseal fixation has promising early results in providing component stability and fixation in revision total knee arthroplasty (TKA). However, there are limited studies on midterm results of metaphyseal sleeves. We analyzed complications, rerevisions, and survivorship free of revision for aseptic loosening of metaphyseal sleeves in revision TKA.

Cemented vs Uncemented Femoral Components: A Randomized,Controlled Trial at 10 Years Minimum Follow-Up

BackgroundThe type of total knee arthroplasty (TKA) fixation (cemented or uncemented) is still subject to debate. The aim of this study is to assess the survival rate, clinical outcomes, and radiological results of TKA according to the fixation type.MethodsA total of 130 patients were randomly assigned to either the cement group (cemented femoral and tibial implants) or the hybrid group (cemented tibial implant, uncemented femoral implant). The inclusion criteria were patients between 50 and 90 years old who underwent primary TKA for osteoarthritis between 2004 and 2005 without a history of open knee surgery. Revisions and complications were reported, as well as clinical scores and radiological signs of loosening.ResultsOne hundred eighteen patients had complete data at 10 years of minimum follow-up (59 in each group). The mean age was 72 years old. The mean follow-up was 13 years. The survival rate was 98% at 13 years in both groups (1 aseptic loosening at 2 years in the cement group, 1 septic loosening in the hybrid group). The complication rate in the cement group was 8.5% (n = 5) vs 12.1% (n = 7) in the hybrid group (P = .8). The clinical results were not significantly different. In the cement group, 25% of patients (n = 15) had radiolucent lines at 10 years. In the hybrid group, 33% of patients had bone transparencies, not evolving or symptomatic.ConclusionAt a minimum follow-up of 10 years, there were no significant differences between cemented TKA and hybrid TKA for the survivorship, the complication rate, the clinical scores, or the radiological signs of loosening.Level of EvidenceI.     

Cementless porous-coated total knee arthroplasty: 10-year results in a consecutive series

We report the results of 114 AGC 2000 porous-coated, cementless total knee arthroplasties (TKA) performed consecutively in 102 patients during the period 1984-1986. After 10 years, 58 TKAs in 52 patients were evaluated with patient assessment, Hospital for Special Surgery knee score, weight-bearing radiographs done under fluoroscopic control, and survivorship analysis. All dropouts within the first 9 years were patients dying with a functioning TKA except 1 revision secondary to a supracondylar fracture after 8.5 years. Of the patients, 53 (92%) were satisfied or very satisfied with their TKA, and 55 (95%) of the knees were rated good or excellent. There was no pain in 53 knees, and the median knee flexion was 110 degrees. Six radiolucencies >1 mm were found beneath parts of the tibial component, and 5 radiolucencies were seen beneath the femoral component. None had progressed compared with the 5-year follow-up, and in all cases trabeculae could be seen reaching the prosthetic component. No migrations had occurred since the 5-year follow-up. No obvious joint space reduction was seen. Osteolysis presenting as an isolated cyst was found in 1 knee in the lateral tibial condyle and was not progressive. Two tibial components had been revised because of aseptic loosening and 1 because of septic loosening, all within the first 3 years. No femoral or patellar components were revised. The cumulative prosthesis survival rate after 10 to 11 years was 97%. When pain and radiographic loosening also were considered, the success rate was 87%. Cementless insertion of a nonmodular, porous-coated TKA resulted in a long-term durable bone-prosthesis interface. The flat-on-flat articulation did not result in catastrophic polyethylene wear or osteolysis within the first 10 years.