Abstract
There is no question that at some point many TKAs will be cementless-the question is when. The advantages of cementless TKA include a shorter operative time, no need for a tourniquet, more suitability for MIS, no concern for cement extrusion, and the history of THA. The concerns for cementless TKA include the history to date with cementless TKA (tibia and metal-backed patella), variable bony substrate, surgical cut precision, cost, revision concerns, and the patella (for patella component resurfacers).
Cemented total knee arthroplasty remains the gold standard and has proven to provide durable results in most patients. The early experience with cementless tibial fixation was problematic due to tibial micromotion leading to pain and loosening. Screw fixed tibial components had additional problems as portals for polyethylene debris leading to tibial osteolysis. Moreover, metal-backed patellar components were associated with a high failure rate and most surgeons began to cement all three components.
Renewed interest in cementless tibial fixation is driven in part by newer materials felt to be more suitable for ingrowth and by the perceived benefit of minimally invasive surgery. One of the concerns in limited exposure total knee arthroplasty is the difficulty in preventing the extravasation of cement posteriorly. If there is evidence-based data that quad sparing non-patella everting and limited incision length facilitates rehabilitation and does not jeopardise outcome, cementless tibial fixation will be a more attractive option in some patients. An additional concern is that the tibial surface is frequently quite variable in terms of the strength of the cancellous bone. Bone cement stabilises those differences and provides a homogeneous platform for load bearing through the tibial component.
