Why I do use uncemented implants. Jean-Luc LERAT Bernard MOYEN (Centre Hospitalier Lyon-Sud) 11èmes Journées Lyonnaises de Chirurgie du genou Oct 2004. Since 30 years surgeons argue about the use of cement for TKA Nevertheless
(Centre Hospitalier Lyon-Sud)
11èmes Journées Lyonnaises de Chirurgie du genou
First uncemented prostheses :1970 (diffusion after1980)
After some years, literature pointed out complications related to implant designs, poly wear, osteolysis, metallic debris.
CEMENT, negative points :
CEMENT, negative points :
CEMENTLESS, negative points :
In favour TKAofuncemented TKR ( f.up >10y)
Onsten I, Norqvist A, Carlsson AS, Bejaskov J, Shott S. AJ Bone Joint Surg 1998
Hydroxyapatite augmentation of the porous coating improves fixation of tibial component: a
randomised RSA study in 116 patients
Witheside LA.Clin Orthop 2001
Long-term followup of the bone-ingrowth Ortholoc Knee System without a metal-backed patella
Hofmann AA. Hofmann AA, Evanich JD, Ferguson RP. Clin Orthop 2001
Ten to 14-year clinical followup of the cementless Natural Knee
300 TKR 10 yrs survival 95.1 %
Dixon P, Parish EN, Chan B, Chitnavis J, MJ Cross. J Bone Joint Surg 2003
Hydrxyapatite-coated, cementles total knee replacement in patients aged 75 years and over
Lachiewicz PF. Cement versus cementless total knee replacement : is there a place for cementless fixation in 2001.Current opinion in orthopaedics 2000
RSA study : bony fixation more secure with cement. Some cementless design have good results.
The main drawback: uncemented implants are too expensive!
McCaskie AW et al. Randomised, prospective study comparing cemented and cementless total knee replacement. Results of press-fit condylar knee replacement at five years, J Bone Joint Surg 1998
Prospective randomised study on 139 TKR. At 5 years f.up frequent lucent lines with cement.
BUT uncemented implant are too expensive!
Duffy GP et al. Cement versus cementless fixation in total knee arthroplasty. Clin Orthop 1998
Prospective study of 55 Press fit condylar (PFC) vs 51cemented PFC .
More revision in the uncemented group (patellar problems).Survival rate10 ys: 72 % vs 94 %
Berger RA et al. Long term followup of the Miller-Galante total knee replacement. Clin Orthop 2001
172 cemented TKR « Miller-Galante I » vs 109 « Miller-Galante II » f.up 11ys.
Survival rate 84% for MG I and 100% for MG II. Difference due to patellar problems of the MGI
Several studies confirm these data concerning patellar implant
Khaw FM et al. A randomised controlled trial of cemented vs cementless press-fit condylar total knee replacement. Ten year survival analysis.
J Bone Joint Surg 2002
277 cemented PFC vs 224 cementless : survival rate : 96,5 % - 96,6 % f.up 10 ys.
Bassett RW. Results of 1000 performance knees: cementless versus cemented fixation.
J Arthroplasty 1998
584 cementless vs 416 cemented TKR f.up 5 ys (survival rate 99%)NO difference
Buechel FF et al. Twenty-year evaluation of meniscal bearing and rotating platform knee replacements. Clin Orthop 2001
373 LCS New Jersey (64 cemented, 104 cementless porocoat CR, 109 rotating). Survival rate : 97,7 % f.up 10 yrs and 20 yrs. NO difference for bony fixation.
Parker DA et al. Long-term followup of cementless versus hybrid fixation for total knee arthroplasty. Clin Orthop 2001
100 Miller-Galante I, with or without cement : NO difference after 12.8 ys
The mechanical behaviour is variable according to the implant designs
Walker PS et al. J Bone Joint Surg 1981
Study of 12 cemented tibial implants on cadaveric tibias
The best fixations were obtained with :
- Full poly plateau
- Monobloc metal-backed implant (with one or two pegs)
With cementless implants, a cadaveric
experiment is obviously Impossible!
Polyethylene pegs (Freeman)
Porous metal (Hungerford)
Titanium mesh (Miller-Galante)
Polyethylene Calcium Hydroxyapatite Titanium micro spheres
Titanium meshCSTI TM
CSTi implant designsTM Interface Microstructure
CSTi TM (Natural – INNEX)
Pores : 4 - 500 microns
Pores : 4 - 500 microns
RSA studies : implant osteointegration and stability implant designs
- Fuiko Ret al. Osteointegration and implant position after cementless total knee replacement. Clin Orthop 2003
101 uncemented LCS New Jersey
- Onsten I et al. A Hydroxyapatite augmentation of the porous coating improves fixation of tibial component: a randomised RSA study in 116 patients. J Bone Joint Surg 1998
146 « Press fit condylar » (PFC) 49 cemented, 47 with porous coating and 50 porous+HAC : No difference
- Hofmann AA et al. 10 to 14-year clinical followup of the cementless Natural Knee System.
Clin Orthop 2001s
176 Natural Knee with CSTI survival rate of 95% , f.up 10 ys.
202 « Ortholoc porous coated » survival rate of 98.6% f.up 18 ys
Osteo integration of cementless implants implant designs
A Reality !
Stable with time !
Stability is quickly obtained
- if the bony cuts are correctly done
- if implants are in contact with the spongious bone
- and covering cortical bone
The post op rehabilitation is the same in the 2 groups
Cemented or cementless
Femur : In the literature femoral osteointegration is not a problem.
Tibial fixation is more controversial :
Osteolysis had been described (could be related to poly wear debris)
But osteointegration is successfull
Loosening should not be confused with fixation failure !
The results depend on many factors
Cemented «Total condylar»
Uncemented «LCS New-Jersey»
Similar survival rate
BUT tibial plateaus are different
- « all poly » for Total condylar
- Rotatory «metal-backed» for LCS
In favour of cemented MB
Gill GS, Joshi HB. Long-term results of Kinematic condylar knee replacement:
404 « Kinematic » cemented CR . Survival rate: 92.6 % f.up 17 ys
Laskin RS. The Genesis Total knee System. A 10-year followup study. Clin Orthop 388, 95-102 2001
100 TKR cemented« Genesis » : Survival rate 97 % f.up 10 ys ( with or without PCL)
Lachiewicz PF. Cement versus cementless total knee replacement : is there a place for cementless
fixation in 2001. Current opinion in orthopaedics 2001
In favour of cemented full poly
Rodriguez JA et al Total Condylar Knee Replacement. A 20-year followup study. Clin
Brassard MF, Insall JN et al. Does modularity affect clinical success? A comparison with a
minimum 10-year followup. Clin Orthop 2001; 388: 26-32
74 TKR « Insall-Burnstein full Polyethylene » vs 82 TKR « Insall-Burnstein MB ».
radio lucent line : 29%: MB , vs 11% full poly, but no clinical difference.
Survival rate f.up 11 ys : 92,6 % and 98 %.
Drawbacks of the MB : categoriePolyethylene wear
Noble et al.Clin Orthop 2003
Wear : cemented TKR : 35 %, non cemented TKR: 25 % .
+ Impingements with cement fragments
Cuckler et al. Polyethylene damage on the nonarticular surface of modular total knee prostheses. Clin Orthop 2003
Polyethylene can be wear out along the non articular tibial surface with modular
Reilly, Walker et al. Effects of tibial component on load transfer in the upper tibia. Clin Orthop 1982
387 cemented TKR « AGC » Survival rate : 94.3 % f.up 10.7ys
Comparison moulded 4.4 mm poly plateau on a 3.6 mm metallic plateau vs 10mm all poly plateau : NO difference.
4583 TKR cemented « AGC » (except 348 cemented femurs) with PCL and a moulded poly plateau on metal: survival rate 98.8% at 15 ys.
F.up:10 ys Survival rate : 92 % for cemented non modular MB plateaus
90 % for cemented modular MB plateaus
97 % for cemented all poly plateaus
Cement : 1408 (THA + TKA)
Cementless : 2991
For my last 500 consecutive TKR, cement has still been used :
- for 17 femurs ( 3.1 %)
- for 70 tibias ( 15 %)
Other features of the series :
480 knees are CR (PCL) (96 %)
Only 4 % of patella resurfaced
- In case of hinge TKR
- For some revisions
- In case of large bony defects when a bone graft
could delay the weight bearing
« Goëland »
Survival rate : 94 %
f.up : 10 to 16 ys
when the bone cuts are good plateaus
Cementless shortens the procedure
The best cement is spongious bone under the implant before impaction
Preservation of the bone stock is an important issue for the future
Removal of the implant
Rare case of osteolysis under the medial plateau
Case of a cementless tibial implant plateaus : osteolysis with progressive subsidence 2-6 months p.o
In case of cemented TKR loosening is the only answer
Hofmann AA et al. Ten to 14-year clinical followup of the cementless
Natural Knee System. Clin Orthop 2001
Tilting, then stabilisationin this bad position.
Revision to correct flexion contracture
Difficulties to separate implants from bone !!
Constrained TKR for :
Important articular damages
With non constrained prostheses
I stil use cemented TKR osteointegration even lately
With non constrained prostheses
Revision for a septic case (2 stages)
But revisions are possible with cementless TKR osteointegration even lately
500 recent primary TKR during the same time :
66 TKR were revised
21 uncemented femurs
24 uncemented tibias
Metal back have many advantages :
In primary cases, cementless or cemented TKA are similar
Cement is usefull when the bony conditions are poor
The question is rather : Why should I use cement when it is not necessary ?