The Journal of Arthroplasty 33 (2018) 1089e1093

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Primary Arthroplasty

Results of Cemented vs Cementless Primary Total Knee Arthroplasty

Using the Same Implant Design
Adam J. Miller, BS a, Jeffrey D. Stimac, MD b, Langan S. Smith, BS b, Anthony W. Feher, MD c,
Madhusudhan R. Yakkanti, MD d, Arthur L. Malkani, MD e, *
a
University of Louisville School of Medicine, Louisville, Kentucky
b
KentuckyOne Health Medical Group, Louisville, Kentucky
c
Franciscan Health Total Joint Reconstruction, Carmel, Indiana
d
Louisville Orthopaedic Clinic, Louisville, Kentucky
e
Department of Orthopaedic Surgery, University of Louisville Adult Reconstruction Program, Louisville, Kentucky

a r t i c l e i n f o a b s t r a c t

Article history: Background: Although cemented total knee arthroplasty (TKA) continues to be the gold standard, there
Received 19 September 2017 are patient populations with higher failure rates with cemented TKAs such as the obese, morbidly obese,
Received in revised form and younger active males. Cementless TKA usage continues to increase because of the potential benefits
13 November 2017
of long-term biologic fixation similar to the rise in cementless total hip arthroplasty. The purpose of this
Accepted 17 November 2017
Available online 2 December 2017
study was to evaluate the clinical and radiographic results of cementless TKA using a novel highly porous
cementless tibial baseplate.
Methods: This was a retrospective matched case-control study of 400 primary TKAs comparing
Keywords:
primary TKA
cementless vs cemented TKAs using the same implant design (Stryker Triathlon; Stryker Inc, Mahwah,
cementless NJ). Two-hundred patients with a mean age of 64 years (range 42-88 years) and body mass index (BMI)
cemented of 33.9 kg/m2 (range 19.7-57.1 kg/m2) were matched to 200 primary cemented TKA patients with a mean
outcomes age of 64 years (range 43-87 years) and BMI of 33.1 kg/m2 (range 22.2-53.2 kg/m2). The mean follow-up
aseptic loosening in the cementless group was 2.4 years (range 2-3.5 years) and in the cemented group was 5.3 years
(range 2-10.9 years). Clinical and radiographic analyses were evaluated. Statistical analysis was per-
formed using the Microsoft Excel, version 15.21.1.
Results: There was no statistical difference in age, BMI, and preoperative Knee Society Scores between
the 2 groups (P ¼ .22, P ¼ .82, and P ¼ .43, respectively). Patients in both groups had a similar incidence of
postoperative complications (P ¼ .90). Cementless group had 7 revisions with one aseptic loosening of
the tibial component (0.5%). Cementless tibial baseplates demonstrated areas of increased bone density
at the pegs of the tibial baseplate. The cemented group had 8 total revisions with 5 cases of aseptic
loosening (2.5%).
Conclusion: Early results of cementless TKA using a highly porous tibial baseplate designed with a keel
and 4 pegs appear promising with one case of aseptic loosening at minimum 2-year follow-up. As the
demographics of patients undergoing TKA change to include younger, obese, and more active patients,
along with increased life expectancy, the use of a highly porous cementless tibial baseplate may be
beneficial in providing long-term durable biologic fixation similar to the success of cementless total hip
arthroplasty.
© 2017 Elsevier Inc. All rights reserved.

Cemented total knee arthroplasty (TKA) continues to be the gold

One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.arth.2017.11.048.
* Reprint requests: Arthur L. Malkani, MD, University of Louisville Adult Recon-
struction Program, 550 S. Jackson Street, 1st Floor, ACB, Louisville, KY 40202.
standard for primary TKA. However, patient demographics are
changing to include younger, obese, and more active patients [1e3].
Cemented TKAs have demonstrated higher failure rates in certain
groups such as obese and younger patients [4e6]. This poses a
challenge to orthopedic surgeons as the largest growth rate for
prospective TKAs is occurring in the <65-year-old patient popula-
tion. The <65 group is expected to represent the majority (>50%) of

https://doi.org/10.1016/j.arth.2017.11.048
0883-5403/© 2017 Elsevier Inc. All rights reserved.
1090 A.J. Miller et al. / The Journal of Arthroplasty 33 (2018) 1089e1093

the anticipated primary TKA burden between 2010 and 2030 [1]. Table 2
Life expectancy has also increased creating further need for Patient Demographics and Outcome Variables Comparing Matched Cementless and
Cemented Cohorts in Total Knee Arthroplasty.
implants to provide more durable long-term fixation similar to the
success of cementless total hip arthroplasty (THA) [6e8]. Demographic Cementless (n ¼ 200) Cemented (n ¼ 200) P Value
The past results of cementless TKA have not been favorable Age, y 64.3 ± 8.3 64.4 ± 8.2 .82
because of multiple reasons including patch porous coating, poor Gender 1
tibial locking mechanisms, and use of first-generation polyethylene Male 74 (37.0%) 74 (37.0%)
Female 126 (63.0%) 126 (63.0%)
leading to osteolysis with migration of particles through screw
Side .904
holes [9,10]. These earlier cementless TKA design iterations were Left 103 (51.5%) 68 (49.2%)
unsuccessful and suffered from a variety of setbacks. Many of these Right 96 (48.0%) 70 (51.8%)
earlier cementless designs did not offer adequate mechanical BMI, kg/m2 33.9 ± 7.5 33.1 ± 6.5 .22
Follow-up time, mo 27.6 ± 3.5 63.4 ± 23.0 <.00001
fixation for immediate implant stability irrespective of the
complications leading to osteolysis [11]. With an understanding of BMI, body mass index.
these failure mechanisms and advances in biomaterials, most of the
earlier design flaws have been corrected leading to improved
survivorship of cementless TKA implants (Table 1). Given the cemented group consisted of a posterior-stabilized or cruciate-
success of cementless THA and the increased demands placed on retaining Stryker Triathlon total knee with a cemented all
current cemented TKA designs because of younger and more active polyethylene patella component. The cementless, screwless, tibial
patients and greater life expectancy, the use of cementless TKA baseplate was developed from pure titanium powder using addi-
needs to be further evaluated. The purpose of this study was to tive manufacturing technology which can optimize porosity for
compare the results of cementless TKA using a novel highly porous ingrowth and provide solid material for strength in addition to
tibial baseplate with a keel and 4 pegs with a cemented TKA using manufacturing complex geometries. Mechanical testing of this
the same kinematically designed total knee implant. cementless tibial baseplate demonstrated excellent resistance to
lift off [24].
The cementless group received a periapatite-coated cementless
Materials and Methods femoral component in all cases, along with a cementless patellar
component. All components implanted in the cohort were
This was a retrospective matched case-control study performed cemented including the use of an all polyethylene cemented patella
at the same institution with institutional review board's approval. component. Most of the cemented total knees were performed
Two-hundred cementless TKAs (Stryker Triathlon; Stryker Inc, before the introduction of the highly porous tibial baseplate. The
Mahwah, NJ) were performed between June 2013 and September selection criteria for cementless TKA was based on the bone quality.
2014 using a highly porous tibial baseplate with a keel and 4 pegs Patients with adequate bone quality at the periphery or rim of the
were reviewed. These were compared with a matched cohort using tibial metaphysis were selected for cementless fixation. The selec-
a cemented TKA with the same kinematic design (Stryker Triathlon) tion process was consistent and performed by the same surgeon.
from a prospective total joint registry. The cementless group The same anesthesia and postoperative care protocol were used in
consisted of 125 women and 74 men, with an average age of 64 both groups including regional anesthesia with a combined femoral
years (range 42-88 years), average body mass index (BMI) of and sciatic nerve block along with intravenous sedation or general
33.9 kg/m2 (range 19.7-57 kg/m2), and a mean follow-up of 2.4 anesthesia. In each case, a pneumatic tourniquet was used and
years (range 2-3.5 years). The matched cohort consisted of 200 postoperative drains were placed before closure. The same
cemented TKAs with 125 women and 74 men, with an average age postoperative physical therapy protocol was also used in both
of 64 years (range 47-87 years), average BMI of 33 kg/m2 groups which consisted of immediate weight bearing with passive
(range 22-53 kg/m2), with a mean follow-up of 5.3 years (range and active motion exercises. All patients received the same pre-
2-10.9 years) (Table 2). operative antibiotic and postoperative venous thromboembolism
All primary cementless knee arthroplasties were performed prophylaxis protocol.
using a parapatellar or subvastus approach and a posterior- Both cohorts were analyzed for primary outcome measures
stabilized Stryker Triathlon Tritanium tibial baseplate along with along with preoperative and postoperative range of motion, pre-
a cementless periapatite-coated femoral component, a cementless operative and postoperative Knee Society Scores (KSS), and medical
patella component, and cross-linked polyethylene liner (Fig. 1). The or surgical complications. Radiographs were obtained at follow-up
visits to evaluate signs of progressive radiolucent lines, osteolysis,
Table 1 component loosening, malalignment, and subsidence (Fig. 2).
Cementless TKA Survivorship Studies. Analysis of the study group and the matched cohort was performed
Research Group Length of Survivorship, % Design using Microsoft Excel, version 15.21.1 (Microsoft Corporation,
Follow-Up, y Redmond, WA). Two-tailed independent t test was used for
Harwin et al (2015) [12] 4 99.50 Triathlon continuous variables with normal distribution. Chi-squared anal-
Kwong et al (2014) [8] 7 95.70 NexGen ysis was used to compare categorical variables. Statistical signifi-
Schroder et al (2001) [13] 10 97.10 AGC-2000 cance was defined as P < .05.
Khaw et al (2002) [14] 10 95.60 PFC
Hofmann et al (2002) [15] 10 99.00 Natural
Watanabe et al (2004) [16] 13 96.70 Osteonics Results
Cross and Parish (2005) [17] 10 99.60 HA
Hardeman et al (2007) [18] 10 97.10 Profix
A total of 400 primary total knee procedures were reviewed in
Tai and Cross (2006) [19] 12 97.50 HA
Kim et al (2014) [20] 17 98.90 NexGen this study consisting of 200 cementless TKAs matched to
Tarkin et al (2005) [21] 17 97.90 LCS-RP 200 cemented TKAs with the same kinematically designed Stryker
Buechel (2002) [22] 20 97.70 LCS-RP Triathlon total knee implant. There were no statistical differences in
Ritter and Meneghini (2010) [23] 20 96.80 AGC age, BMI, and preoperative KSS between the 2 matched cohorts
TKA, total knee arthroplasty. (P ¼ .22, P ¼ .82, and P ¼ .43, respectively; Table 1). The cementless
 A.J. Miller et al. / The Journal of Arthroplasty 33 (2018) 1089e1093 1091

Fig. 1. Picture of a cementless, highly porous tibial baseplate.

group had a slight improved 2-year KSS functional scores compared

with cemented group (76 ± 20.4 for cementless and 70.2 ± 22.3 for
cemented, P ¼ .016). KSS knee scores were also somewhat improved
in the cementless group compared with the cemented group (94.1 ±
6.2 in cementless and 91.5 ± 9.8 in cemented) (P ¼ .007; Table 3).
Each group had similar improvements in KSS, 53.8 ± 13.8 (range
9-80) in the cementless group and 52.4 ± 16.7 (range 0-81) in the
cemented group (P ¼ .47). Cemented and cementless groups had
similar postoperative knee extension of 0.23 ± 1.7 and
0.11 ± 0.9 , respectively (P ¼ .385). The cementless group
demonstrated slight improvement in postoperative knee flexion
compared with the cemented cohort (119.4 ± 7.0 vs 116.4 ± 7.8;
P ¼ .003).
Both groups had similar rates of failure leading to revision
(8 cemented vs 7 cementless, P ¼ .069). There was one case of
aseptic tibial component loosening in the cementless group (0.5%),
whereas there were 5 cases of aseptic loosening in the cemented
cohort (2.5%). Although there were more cases of aseptic loosening
in the cemented group, this comparison was not significant (P ¼ .2;
Table 4). The cementless group had 7 total revisions; one revision
for flexion instability treated with liner exchange, one extensor
Fig. 2. (A) Anteroposterior (A/P), lateral, and merchant radiographs of a 67-year-old
mechanism rupture treated with liner exchange and quad repair,
patient with severe osteoarthritis (OA) of the right knee. (B) A/P, lateral, and merchant
one postoperative infection treated with liner exchange and radiographs 1-year postoperative right total knee arthroplasty (TKA) using highly
irrigation and debridement, one recurrent patellar dislocation with porous cementless tibial baseplate, hydroxyapatite (HA)ecoated cementless femoral
liner exchange and quad tendon repair, and one case where the component and cementless patella component. (C) A/P and lateral radiographs 4 years
patella was not resurfaced during the index procedure which after index procedure with a well-functioning and stable implant and no evidence of
radiolucent lines.
subsequently developed patellofemoral arthrosis requiring patella
arthroplasty. Except for the one aseptic tibial component loosening
in the cementless group, all other cementless cases demonstrated
cemented Stryker Triathlon TKA have demonstrated excellent
radiographic dense spot welding or increased bone density
results in a prior study [25]. However, as the patient population
primarily around the 4 tibial pegs. There were no cases of aseptic
receiving TKA continues to evolve to include obese, younger, and
loosening in either the cementless femoral or patella components.
more active patients who are also living longer, surgeons are faced
The cemented group had 8 total revisions, including 5 cases of
with the challenge of providing durable long-term implant fixation.
aseptic loosening; 1 patellar loosening, 2 tibial component loos-
Gioe et al [26] in a study from 1991-2002 on 5760 primary TKA's
ening, and 2 femoral and tibial component failures. There were
attributed 40% of their revisions due to aseptic loosening. Younger
2 revisions because of flexion instability treated with conversion to
patients with active lifestyles and obese patients pose a challenge to
a posterior-stabilized design, and one case of liner exchange with
irrigation and debridement performed for a traumatic arthrotomy
after a postoperative fall. There were no postoperative infections in
the cemented group and one infection in the cementless group. Table 3
Comparison of Outcome Scores in Matched Cementless vs Cemented TKA.
Each group had a similar incidence of medical and surgical
postoperative complications. Outcome Score Cementless TKA Cemented TKA P Value

KSS function score 76.0 ± 20.4 70.2 ± 22.3 .016

Discussion Change in function score 35.6 (±19.8) 26.04 ± 26.6 .0014
KSS knee score 94.1 ± 6.1 91.6 ± 9.8 .0076
TKA is the treatment of choice for end-stage osteoarthritic knee Change in knee score 53.8 ± 13.8 52.4 ± 16.7 .385

disease when all nonoperative methods have failed. The results of KSS, Knee Society Score; TKA, total knee arthroplasty.
1092 A.J. Miller et al. / The Journal of Arthroplasty 33 (2018) 1089e1093
Table 4
Total Revision Stratification Comparison in Matched Cementless vs Cemented TKA.
Reason for Revision No. of Revisionsd No. of Revisionsd P Value
Cementless TKA Cemented TKA
Aseptic loosening 1 (0.5%) 5 (2.5%)
Infection 1 (0.5%) 0 (0.0%)
Extensor mechanism rupture 1 (0.5%) 0 (0.0%)
Flexion instability 1 (0.5%) 2 (1.0%)
Global instability 1 (0.5%) 0 (0.0%)
Patellar dislocation 1 (0.5%) 0 (0.0%)
Patellofemoral arthrosis 1 (0.5%) 0 (0.0%)
Open arthrotomy 0 (0.0%) 1 (0.5%)
Total no. of revisions 7 (3.5%) 8 (4.0%)
TKA, total knee arthroplasty.
the gold standard of cemented TKA because of concerns of aseptic
loosening [8]. Aseptic loosening is one of the most common etiology
of failure with cemented TKA designs faced by younger and heavier
patients [27e29]. Abdel et al [4] in a review of cemented TKA's
demonstrated increased failure due to aseptic loosening in obese
patients despite well-aligned knees. Bagsby et al [30] demonstrated
higher failure rates with cemented primary TKA compared with
cementless TKA in the morbidly obese, 89% survivorship vs 99%,
respectively. Higher failures rates have also been demonstrated in
younger patients undergoing primary TKA [31]. Gioe et al [31]
showed cemented TKA survival rate at 85% in a cohort (n ¼ 1047)
of patients <55 years old over a 14-year period. Meehan et al [29]
demonstrated that the risk of revision surgery due to aseptic loos-
ening in cemented primary TKA at 1 year postoperatively in patients
<50 years old was 4.7 greater than that of a >65-year-old cohort. A
Kaplan-Meier survivorship analysis from McCalden 2013 showed
primary cemented TKA patients <55 years old with significantly
higher rates of revision due to aseptic loosening at both 5 and 10
years postoperatively compared with cementless TKA.
Given the success of cementless THA, there has been an
increased interest in the use of cementless TKA to provide same
benefits of biologic fixation over mechanical cement fixation for
long-term durability. Initial cementless TKA implants, however,
suffered from design flaws including poor patch porous coatings,
poor tibial locking mechanisms, and use of first-generation
polyethylene that led to increased wear and osteolysis with
poor outcomes [8,10,12]. Ritter and Meneghini [23] looked at
73 cementless knees from 1984-1986 and demonstrated that many
of the early cases of cementless TKA failures were due to the metal-
backed patella. Twelve of the 15 failures leading to revision in their
series were due to patellar component failure with an overall 76.4%
survivorship at 20 years. The survivorship of the cementless femoral
component was 96.8%. Cementless femoral components have
demonstrated excellent survivorship over the long-term in many
series [4,32,33]. Many of the early cementless patella component
failures discouraged orthopedic surgeons away from the use of
cementless TKA implants. These early patellar design failures have
been addressed through numerous improvements including the
use of thicker, current-generation polyethylene, reduction in sharp
metal boarders, and a higher degree of conformity which have led to
highly favorable outcomes without the osteolysis and accelerated
wear noted in first-generation designs [34e37].
Another area of early design failure of cementless TKA was
noted in the higher failure rates of cementless tibial baseplates.
Initial cementless tibial baseplate designs demonstrated increased
incidence of progressive radiolucent lines at the implant/bone
interface leading to aseptic loosening and subsequent component
failure [38,39]. In all likelihood, initial design cementless tibial
baseplates did not provide adequate immediate implant stability
critical for successful biologic ingrowth [40]. Dunbar et al [41] using
radiostereometric analysis demonstrated that immediate rigid
implant stability is essential for successful long-term biological
fixation in a study of cementless TKA.
Despite the initial setbacks in early cementless tibial component
.212 designs, these design flaws have mostly been addressed leading to
.316 a reevaluation of cementless TKA. Harwin et al [12] in a review of a
.316 cementless modern design TKA with periapatite coating to improve
.562
the potential of biologic fixation along with screw fixation on the
.316
.316 tibial baseplate to provide immediate rigid fixation demonstrated
.316 99% survivorship at an average of 4 years follow-up. Beaupre et al
.316 [42] in a randomized control trial evaluated a modern design
.069
cementless tibial component coated with hydroxyapatite vs a
cemented tibial baseplate with the same design at 5 years and
demonstrated equivalent outcomes. Cross and Parish [17] reviewed
a cohort of 1000 patients who received a hydroxyapatite-coated
cementless TKA implants with a survivorship of 99% at 10 years
with aseptic loosening as the end point. Bagsby et al [30] demon-
strated 99% survivorship at 3.6 years with cementless TKA
compared with 89% survivorship with cemented TKA in the
morbidly obese patient. Several other studies have demonstrated
improved survivorship of cementless TKA compared with the
results of earlier cementless designs [20,43].
Because of the challenge of obtaining rigid fixation in early
cementless design, adjunctive fixation mechanisms were used in
earlier designs [3]. Screws were used in tibial baseplates to help
insure initial stability of the implant to increase the probability of
adequate biological fixation [44,45]. However, tibial screws served
as a conduit for osteolysis via formation channels for debris [3,11].
Holloway et al [46] showed reliable fixation with screwless
cementless tibial baseplates at an average of 7.6 years follow-up.
Other studies have also demonstrated no advantage to using
tibial baseplate with screws vs no screws [47,48].
With advances in technology, new implants have been devel-
oped using highly porous components which have obviated the
need for adjunct tibial baseplate screw fixation to provide imme-
diate implant stability [9,49,50]. The cementless tibial baseplate
used in this study was developed using additive manufacturing
3D printed technology with a keel and 4 pegs designed to provide
immediate implant stability [24]. Nam et al [50] in a similar study
comparing cementless vs cemented total knee implants demon-
strated no difference in blood loss and change in hemoglobin, but
did show decreased operative time in the cementless group.
In our study, at an average follow-up of 2.4 years after TKA using
a cementless highly porous tibial baseplate, we demonstrated a
failure rate due to aseptic loosening of 0.5%. The matched cemented
cohort used in this study with the same implant design had an
aseptic failure rate of 2.5% (P ¼ .09). Given the history of cementless
THA, once biological fixation is achieved with cementless TKA, in all
probability it should remain durable over the long-term.
Radiographic analysis of the cementless tibial baseplate used in
this study demonstrated areas of dense bone ingrowth or spot
welds primarily at the pegs similar to the areas of bone density
noted at the screws sites with cementless THA [51]. It is difficult to
quantify the amount or extent of biological fixation in cementless
implants with plain radiographs. Future studies using micro
computed tomographic or extreme computed tomographic scans
would help quantify the exact location and extent of ingrowth in
these highly porous implants [52]. Some of the strengths of this
study include the use of the same kinematically designed TKA
implant at the same institution along with the same anesthesia and
postoperative therapy protocol with the cemented cohort matched
from the same prospective database.
Given the higher failure rates of cemented TKA in younger,
active, and obese patients along with increased life expectancy,
there has been an impetus toward the use of cementless TKA with
 A.J. Miller et al. / The Journal of Arthroplasty 33 (2018) 1089e1093
the potential of long-term durable biological fixation similar to the
history and evolution of cementless THA use in North America. The
results of our study using a highly porous tibial baseplate with a
keel and 4 pegs designed for immediately implant stability
demonstrated excellent short-term results and a failure incidence
due to aseptic loosening equivalent or somewhat better compared
with a kinematically designed similar cemented implant. Many of
the early design flaws of cementless TKA leading to increased wear,
osteolysis, and loosening have been addressed, especially with
current-generation polyethylene and improved fixation methods
using highly porous implants. Based on our study, young active
patients and obese patients who place greater demands and stress
at the bone-implant interface may benefit from the use of
cementless TKA to obtain the benefits of durable long-term biologic
fixation. Although the early results of this study of cementless TKA
is encouraging, additional data are required to determine if the
benefits of biologic fixation using a highly porous, current design
cementless TKA can be realized over the long-term similar to the
history and success of cementless THA.
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