Usage trends of cemented and cementless (uncemented) implants

Cemented and cementless (uncemented) implants preference is very important in knee and hip arthroplasty surgeries. Cemented implants have been available for many years, but complications associated with loosening and eventual failure over time have led to the development of cementless implants. 5 With the development of technology and production techniques, the preference for cementless implants has started to increase.  

With an increasingly active and longer-living population and a tendency to replace joints early in life, efforts to improve implant survival are continuing. An ideal knee or hip implant should biomechanically regenerate a normal joint, allow pain-free function, and maintain the patient’s lifespan without the need for revision.

Previously, early total knee arthroplasty designs with cementless fixation have been associated with a high rate of complications and implant failures. 1,2 However, cemented total knee arthroplasty designs have also been subject to similar reviews, with reports of osteolysis and femoral component loosening. 3,4


There are many factors that can affect the integration, stability and fixation of the implant to the bone. It is necessary to understand these factors well in order to choose the appropriate implant for the patient. 5


In this article, clinical results that explain the increasing preference for cementless implants will be included. In the final evaluation, the importance of surgical saw blade and surgical power tool systems will be emphasized in the use of cementless implants.

Cementless implants had previously given better results only in younger patients. However, the success of cementless implants in recent studies has increased the preference of these implants.  In their 2020 review, Salem et al. gathered together studies showing that cementless total knee implants are an appropriate choice for all demographics below. 6


1) Patients younger than 60 years

2) Patients older than 75 years

3) Obese patients

4) Patients with rheumatoid arthritis

5) Patients with knee osteonecrosis

1) Patients younger than 60 years

Kim et al. 7 performed a study to evaluate the long-term outcomes of total knee arthroplasty in patients younger than 55 years of age undergoing cemented and cementless implants fixation. Bilateral, sequential, simultaneous total knee arthroplasty was performed on all patients, and one knee was cementless and the other was cemented. After a minimum follow-up of 16 years, there was no significant difference in average Knee Society* scores (p = 0.319) in the cementless (95.8; range, 85-99) and cemented (96.7; range, 79-100) groups. Similarly, the mean WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index)** score did not differ significantly between the cementless (25.4; range, 5-51) and cemented (25.9; range, 5-59) groups (p = 0.189) . The authors concluded that the long-term results of both cementless and cemented total knee arthroplasties are encouraging in patients under 55 years of age and there is no evidence of superiority of one fixation method over the other.

Lizaur-Utrilla et al. 8 conducted a study to compare the results of cemented versus cementless fixation in patients under 55 years of age. At a average follow-up of 6-7 years, the average KS score of the cementless group (94 × 9.3) was significantly better than the cemented (89 × 11.8) group (p = 0.022). At the last follow-up, the average pain score was found to be significantly better in the cementless group (47 ± 4.2) compared to the cemented (44 ± 8.1) group. (p = 0.024). The mean WOMAC score of the cementless (88 ± 10.7) groups was found to be significantly higher than the cemented (83 ± 11.4) groups. The 9-year survival rate was 93.7% (95% confidence interval [CI]: 82-100) in the cementless group and 90.0% (95% CI: 80-100) in the cemented group (p > 0.05). The authors concluded that although the survival rates of cementless and cemented total knee arthroplasty structures in patients under 55 years of age are similar, clinical outcomes may be better with cementless tibial fixation.

In summary, the above studies highlight the success of cementless total knee arthroplasty in the younger population. 6

2) Patients older than 75 years

Although cementless total knee arthroplasty prostheses have demonstrated a similar survival profile to cemented designs, their use in the elderly population remains controversial due to concerns about initial fixation of the tibial component, osteointegration at the bone-implant interface, and the ability of osteopenic bone. 6

Newman et al. retrospectively reviewed 134 patients (142 knees) over the age of 75 who applied cementless total knee arthroplasty after a average follow-up of 4 years. Aseptic implant survival rate was 99.3% (95% CI: 7.9-8.1) and all-cause implant survival was 98.6% (95% CI: 7.9-8.1). The mean KS pain score was 93 (range, 80-100) points and the mean KS function score was 84 (range, 70-90) points. 9 The results of this study showed that cementless total knee arthroplasty is an applicable option in patients over 75 years of age.  6

3) Obese patients

Sinicrope et al. 11 conducted a review comparing the clinical results of cemented and cementless primary total knee arthroplasty in morbidly obese patients. It should be noted that the average follow-up time was significantly longer in the cemented group (100 months) compared to the cementless group (72 months). In the cementless group, one case of aseptic tibial loosening occurred (0.9%) and there were no cases of femoral or patellar component loosening. In the cemented group, a total of 16 aseptic implant loosening (18.8%, p = 0.0001) occurred, including 10 tibial components, 5 femoral components, and 1 patellar component. A total of 22 failures (25.9%) requiring revision surgery were detected in the cemented group, and 5 (5.4%) in the cementless group (p=0.001). The overall implant survival rate in the cemented group was 92.9% at 5 years, 88.2% at 8 years, and 83.5% at 12 years. In the cementless group, overall implant survival was 99.1% at 5 (p = 0.09) and 8 years (p = 0.02), respectively.  6

Boyle et al. found a survival rate of 98.1% (95% CI: 94.1-99.4) in the cementless group and 98.3% (95% CI: 94.7-99.4) in the cemented group in their comparison. 12 The results of this study demonstrated that the cementless or cemented cruciate retaining design similarly survived with respect to aseptic loosening of the tibial baseplate and overall revision rates in obese patients undergoing total knee arthroplasty. 6

4) Patients with rheumatoid arthritis

The authors noted that the decision to use cemented or cementless total knee arthroplasty implants in patients with rheumatoid arthritis should be based on surgeon experience and patient characteristics. 6

In a retrospective review by Hotfiel et al., the survival rate for cementless total knee arthroplasty implants was 100% after 5 years, 97.1% (95% CI: 89.0–99.2) after 10 years, and 95.6% (95% CI: 86.9–98.5) after 15 years. The authors concluded that excellent clinical outcomes and a good 10-year survival can be achieved with cementless tibial fixation for total knee arthroplasty in patients with rheumatoid arthritis. 13

Woo et al. retrospectively analyzed 112 patients (179 total knee arthroplasty) with cementless fixation of three different implant systems. Average follow-up was 10.1 (range, 4.6–15.5) years. Loosening of the tibial component was observed in one knee 8.4 years after surgery. While the average KS knee and function scores were 47.5 and 43.6 preoperatively, they increased to 91.2 and 82.3 at the last follow-up. The overall survival rate was 96.8% at last (15.5 years) follow-up. The results of this study show that cementless fixation is an applicable option for patients with rheumatoid arthritis undergoing total knee arthroplasty. 14

5) Patients with knee osteonecrosis

In some cases of knee osteonecrosis, total knee arthroplasty is the only option to improve the pain and dysfunction caused by this disease. 15,16 Salem et al. stated that necrotic bone in the subchondral area may prevent the use of cementless fixation of total knee arthroplasty components. Faizan et al. reported that living bone with regenerative capacity is required for cementless fixation success. 17 Therefore, implant stability and ultimately the survival of cementless total knee arthroplasty implants may be difficult in the occurrence of osteonecrosis. 6

Sultan et al. evaluated 46 patients (49 knees) with knee osteonecrosis who applied primary cementless total knee arthroplasty. The aseptic implant survival rate in the cohort was 97.9% and the all-cause implant survival rate was 95.9%. The average CS pain score was 93 (range, 85-100) and the average KS function score was 84 (range, 70-90). 18

Studies have shown that cementless implants can also be successful in patients with knee osteonecrosis.


The selection of cemented and cementless implants is made by the doctor according to the characteristics of the patient. Recent studies have shown that cementless implants can be applied in a wide variety of patient demographics.

The deficiencies, side effects, and toxicity of bone cement have been addressed recently. In the formation of bone cement, heat is produced due to an exothermic reaction. During this reaction, the cement heats up and reaches temperatures of 82°C – 86°C.  10 Bone necrosis is known to start at 47°C – 50°C. For this reason, bone warming values, which are taken into account when cutting with a surgical saw blade, do not matter much in cemented implants. It is only necessary to make a smooth incision without deviation so that the entire cement thickness on the surface of the bone is equal.

The widespread use of cementless implants increases the importance of surgical saw blade and surgical power tool systems in these operations.

In cementless implant systems, a smooth and precise incision is very important for prolonging the survival of the implant. The fact that the bone surface on which the prosthesis will be placed is not suitable (at the desired angle and smooth) is a reason for aseptic loosening.

When using cementless implants, attention should be paid to the heat generated in cutting and drilling operations performed with surgical power tool systems.

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