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.

References

1. No authors listed. Online LROI annual report 2017: 10 years of registration, a wealth of information. Dutch Arthroplasty Register (LROI).. https://www.lroi-rapportage.nl/ (date last accessed 01 May 2020). Google Scholar
2. No authors listed. National Joint Registry 14th Annual Report. National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR). 2017. https://www.hqip.org.uk/resource/national-joint-registry-14th-annual-report-2017/#.XqwC9ahKg2w (date last accessed 01 May 2020). Google Scholar
3. No authors listed. Annual Report 2017. Swedish Knee Arthroplasty Register. http://www.myknee.se/pdf/SVK_2017_Eng_1.0.pd (date last accessed 01 May 2020). Google Scholar
4. Dalury DF. Cementless total knee arthroplasty: current concepts review. Bone Joint J. 2016;98-B(7):867–873. Link, ISI, Google Scholar
5. Meneghini RM, Hanssen AD. Cementless fixation in total knee arthroplasty: past, present, and future. J Knee Surg. 2008;21(4):307–314. Crossref, Medline, Google Scholar
6. Trauner KB. The emerging role of 3D printing in arthroplasty and Orthopedics. J Arthroplasty. 2018;33(8):2352–2354. Crossref, Medline, ISI, Google Scholar
7. Mumith A, Thomas M, Shah Z, Coathup M, Blunn G. Additive manufacturing: current concepts, future trends. Bone Joint J. 2018;100-B(4):455–460. Link, ISI, Google Scholar
8. Hu B, Chen Y, Zhu H, Wu H, Yan S. Cementless porous tantalum Monoblock tibia vs Cemented modular tibia in primary total knee arthroplasty: a meta-analysis. J Arthroplasty. 2017;32(2):666–674. Crossref, Medline, ISI, Google Scholar
9. Mont MA, Pivec R, Issa K, et al. Long-term implant survivorship of cementless total knee arthroplasty: a systematic review of the literature and meta-analysis. J Knee Surg. 2014;27(5):369–376. Medline, ISI, Google Scholar
10. Zhou K, Yu H, Li J, et al. No difference in implant survivorship and clinical outcomes between full-cementless and full-cemented fixation in primary total knee arthroplasty: a systematic review and meta-analysis. International Journal of Surgery. 2018;53:312–319. Crossref, Medline, ISI, Google Scholar
11. Gandhi R, Tsvetkov D, Davey JR, Mahomed NN. Survival and clinical function of cemented and uncemented prostheses in total knee replacement: a meta-analysis. J Bone Joint Surg Br. 2009;91-B(7):889–895. Link, ISI, Google Scholar
12. Sporer S, MacLean L, Burger A, Moric M. Evaluation of a 3D-printed total knee arthroplasty using radiostereometric analysis: assessment of highly porous biological fixation of the tibial baseplate and metal-backed patellar component. Bone Joint J. 2019;101-B((7 Supple C):):40–47. Link, Google Scholar
13. Laende EK, Astephen Wilson JL, Mills Flemming J, et al. Equivalent 2-year stabilization of uncemented tibial component migration despite higher early migration compared with cemented fixation: an RSA study on 360 total knee arthroplasties. Acta Orthop. 2019;90(2):172–178. Crossref, Medline, ISI, Google Scholar
14. Laende EK, Richardson CG, Dunbar MJ. Predictive value of short-term migration in determining long-term stable fixation in cemented and cementless total knee arthroplasties. Bone Joint J. 2019;101-B(7 Supple_C):55–60. Link, Google Scholar
15. Pijls BG, Valstar ER, Nouta KA, et al. Early migration of tibial components is associated with late revision: a systematic review and meta-analysis of 21,000 knee arthroplasties. Acta Orthop. 2012;83(6):614–624. Crossref, Medline, ISI, Google Scholar
16. Pijls BG, Plevier JWM, Nelissen RGHH. Rsa migration of total knee replacements. Acta Orthop. 2018;89(3):320–328. Crossref, Medline, ISI, Google Scholar
17. Ryd L, Albrektsson BE, Carlsson L, et al. Roentgen stereophotogrammetric analysis as a predictor of mechanical loosening of knee prostheses. J Bone Joint Surg Br. 1995;77-B(3):377–383. Link, Google Scholar
18. Carlsson A, Björkman A, Besjakov J, Onsten I. Cemented tibial component fixation performs better than cementless fixation: a randomized radiostereometric study comparing porous-coated, hydroxyapatite-coated and cemented tibial components over 5 years. Acta Orthop. 2005;76(3):362–369. Crossref, Medline, ISI, Google Scholar
19. Dunbar MJ, Wilson DA, Hennigar AW, et al. Fixation of a trabecular metal knee arthroplasty component. A prospective randomized study. J Bone Joint Surg Am. 2009;91-A(7):1578–1586. Crossref, Google Scholar
20. Pijls BG, Valstar ER, Kaptein BL, Fiocco M, Nelissen RG. The beneficial effect of hydroxyapatite lasts: a randomized radiostereometric trial comparing hydroxyapatite-coated, uncoated, and cemented tibial components for up to 16 years. Acta Orthop. 2012;83(2):135–141. Crossref, Medline, ISI, Google Scholar
21. Van Hamersveld KT, Marang-Van De Mheen PJ, Nelissen RGHH, Toksvig-Larsen S. Peri-apatite coating decreases un-cemented tibial component migration: long-term RSA results of a randomized controlled trial and limitations of short-term results. Acta Orthop. 2018;89(4):425–430. Crossref, Medline, ISI, Google Scholar
22. Ahlbäck S. Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh). 1968;277(suppl 277):7–72. Google Scholar
23. Muth J, Poggie M, Kulesha G, Michael Meneghini R. Novel Highly porous metal technology in artificial hip and knee replacement: processing methodologies and clinical applications. JOM. 2013;65(2):318–325. Crossref, ISI, Google Scholar
24. No authors listed. Implants for surgery – Roentgen stereophotogrammetric analysis for the assessment of migration of orthopaedic implants. International Organization for Standardization (ISO). 2019. https://www.iso.org/about-us.html (date last accessed 01 May 2020). Google Scholar
25. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–14. Google Scholar
26. Roos EM, Lohmander LS. The Knee injury and osteoarthritis outcome score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes. 2003;1:64. Crossref, Medline, Google Scholar
27. Behrend H, Giesinger K, Giesinger JM, Kuster MS. The “forgotten joint” as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty. 2012;27(3):430–436. Crossref, Medline, ISI, Google Scholar
28. Cooke TD, Sled EA, Scudamore RA. Frontal plane knee alignment: a call for standardized measurement. J Rheumatol. 2007;34(9):1796–1801. Medline, ISI, Google Scholar
29. Valstar ER, Gill R, Ryd L, et al. Guidelines for standardization of radiostereometry (RSA) of implants. Acta Orthop. 2005;76(4):563–572. Crossref, Medline, ISI, Google Scholar
30. Kaptein BL, Valstar ER, Stoel BC, Rozing PM, Reiber JHC. A new type of model-based roentgen stereophotogrammetric analysis for solving the occluded marker problem. J Biomech. 2005;38(11):2330–2334. Crossref, Medline, ISI, Google Scholar
31. Molt M, Toksvig-Larsen S. Similar early migration when comparing Cr and PS in Triathlon™ TKA: a prospective randomised RSA trial. Knee. 2014;21(5):949–954. Crossref, Medline, ISI, Google Scholar
32. No authors listed. Power (sample siza) calculators. Sealed envelope. 2012. https://www.sealedenvelope.com/power/continuous-equivalence/ (date last accessed 01 May 2020). Google Scholar
33. Krueger C, Tian L. A comparison of the general linear mixed model and repeated measures ANOVA using a dataset with multiple missing data points. Biol Res Nurs. 2004;6(2):151–157. Crossref, Medline, Google Scholar
34. Ranstam J, Turkiewicz A, Boonen S, et al. Alternative analyses for handling incomplete follow-up in the intention-to-treat analysis: the randomized controlled trial of balloon kyphoplasty versus non-surgical care for vertebral compression fracture (FREE). BMC Med Res Methodol. 2012;12(1):35. Crossref, Medline, Google Scholar
35. Schulz KF, Altman DG, Moher D, CONSORT Group. Consort 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332. Crossref, Medline, Google Scholar
36. Henricson A, Linder L, Nilsson KG. A trabecular metal tibial component in total knee replacement in patients younger than 60 years: a two-year radiostereophotogrammetric analysis. J Bone Joint Surg Br. 2008;90-B(12):1585–1593. Link, ISI, Google Scholar
37. Hansson U, Ryd L, Toksvig-Larsen S. A randomised RSA study of Peri-Apatite™ HA coating of a total knee prosthesis. Knee. 2008;15(3):211–216. Crossref, Medline, ISI, Google Scholar
38. Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty. 2009;24(6 Suppl):39–43. Crossref, Medline, ISI, Google Scholar
39. Mandelin J, Liljeström M, Li T-F, et al. Pseudosynovial fluid from loosened total hip prosthesis induces osteoclast formation. J Biomed Mater Res B Appl Biomater. 2005;74(1):582–588. Crossref, Medline, Google Scholar
40. van Hamersveld KT, Marang-van de Mheen PJ, Nelissen RGHH. The effect of coronal alignment on tibial component migration following total knee arthroplasty: a cohort study with long-term Radiostereometric analysis results. J Bone Joint Surg Am. 2019;101-A((13):1203–1212. Crossref, ISI, Google Scholar
41. Teeter MG, Naudie DD, McCalden RW, et al. Varus tibial alignment is associated with greater tibial baseplate migration at 10 years following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2018;26(6):1610–1617. Crossref, Medline, ISI, Google Scholar
42. Arabnejad S, Johnston B, Tanzer M, Pasini D. Fully porous 3D printed titanium femoral stem to reduce stress-shielding following total hip arthroplasty. J. Orthop. Res.. 2017;35(8):1774–1783. Crossref, Medline, ISI, Google Scholar
43. Miller AJ, Stimac JD, Smith LS, et al. Results of Cemented vs Cementless primary total knee arthroplasty using the same implant design. J Arthroplasty. 2018;33(4):1089–1093. Crossref, Medline, ISI, Google Scholar
44. Nam D, Lawrie CM, Salih R, et al. Cemented versus Cementless total knee arthroplasty of the same modern design: a prospective, randomized trial. J Bone Joint Surg Am. 2019;101-A(13):1185–1192. Crossref, ISI, Google Scholar
45. Sultan AA, Mahmood B, Samuel LT, et al. Cementless 3D printed highly porous titanium-coated baseplate total knee arthroplasty: survivorship and outcomes at 2-year minimum follow-up. J Knee Surg. 2019;33(3):279-283. Medline, ISI, Google Scholar
46. Sinicrope BJ, Feher AW, Bhimani SJ, et al. Increased survivorship of Cementless versus Cemented TKA in the morbidly obese. A minimum 5-year follow-up. J Arthroplasty. 2019;34(2):309–314. Crossref, Medline, ISI, Google Scholar
47. Van Hamersveld KT, Marang-Van De Mheen PJ, Nelissen RGHH, Toksvig-Larsen S. Migration of all-polyethylene compared with metal-backed tibial components in cemented total knee arthroplasty. Acta Orthop. 2018;89(4):412–417. Crossref, Medline, ISI, Google Scholar
48. Nelissen RG, Pijls BG, Kärrholm J, et al. RSA and registries: the quest for phased introduction of new implants. J Bone Joint Surg Am. 2011;93-A(Suppl 3):62–65. Crossref, Google Scholar
49. Nieuwenhuijse MJ, Nelissen RG, Schoones JW, Sedrakyan A. Appraisal of evidence base for introduction of new implants in hip and knee replacement: a systematic review of five widely used device technologies. BMJ. 2014;349:g5133. Crossref, Medline, Google Scholar

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Published online 31 July 2020

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