Historically, cement has been the preferred method of fixation among knee surgeons for total knee arthroplasty (TKA). Although some cementless TKA designs have provided excellent patient results with respect to function and survivorship,¹,²,³,⁴,⁵,⁶ cemented TKA continues to remain the standard by which the success of cementless fixation in TKA is judged.¹,⁷ On one hand, midterm results of cementless posterior-stabilized (PS) TKA have shown 8-year survivorship of 98%⁵ to 99.5%.¹ In addition, longer-term results in cementless cruciate-retaining (CR) TKA have reported excellent survivorship²,³,⁴,⁶ between 93% at 12 years² and 97% at 20 years.⁴ On the other hand, numerous studies of cemented TKA, including a variety of modular, nonmodular, CR, and PS designs, have demonstrated excellent clinical and radiographic outcomes⁸,⁹,¹⁰,¹¹,¹²,¹³,¹⁴,¹⁵,¹⁶,¹⁷,¹⁸ between 98% at 10 years¹²,¹⁴ and 94% at 25 years¹⁷ with survivorship in some cases over 92% into the fourth decade.¹⁷ Furthermore, registry data on 7174 TKAs noted a higher 5-year survival for cemented TKA (95.9%) versus cementless TKA (88.3%) with 2.2 times the risk of early failure with cementless fixation.¹⁹ Finally, a meta-analysis of 15 studies comparing cemented and cementless fixation in TKA found the combined odds ratio for failure due to aseptic loosening was 4.2 for the cementless TKA between 2 and 11 years.²⁰ Thus, as cementless TKA has rarely been shown to be superior to cemented TKA,²¹ careful consideration is needed when choosing cementless fixation over cemented fixation in TKA.

Relative indications for cemented TKA may include poor bone quality, cases where immediate rigid implant fixation in mandatory (multiple lower extremity joint arthritis or inflammatory arthropathy), and when the addition of antibiotics in the cement is desired. However, because concern may exist over the bone-cement interface deteriorating over time,⁵ the so-called “biologic fixation”⁵,²² of cementless TKA may be considered appealing, especially in the relatively younger, heavier, and potentially more active patient.⁵

It is axiomatic that obtaining rigid implant fixation at the time of cemented TKA is a primary goal for the surgeon and a fundamental prerequisite for long-term survivorship. Achieving implant stability while maintaining adequate bone stock is a key objective.²¹ The surgical technique begins with an adequate exposure. This is required not only for proper bone cuts and osteophyte removal but also for bone preparation, cement pressurization, implantation of the prosthesis, and removal of cement excrescences. Commonly, the tibia is subluxed anterior to the femur, with or without eversion of the patella. Because optimal implant fixation requires 3 to 4 mm of cement penetration into bone,²³ sclerotic bone may be drilled at this time creating multiple fenestrations allowing the cement to penetrate into more cancellous bone (Fig. 37-1A). Blood and bone debris inhibit cement penetration and can decrease the shear strength at the bone-cement interface by 50%²⁴ (Fig. 37-1B). This interlock is the main factor in interface strength. Thus, the bone surfaces must be thoroughly cleaned with high-pressure, high-volume, jet lavage. Simple manual syringe irrigation has been shown to be inferior with respect to cement penetration into bone. Ritter et al. clearly demonstrated that proper bone preparation, jet lavage, suction drying, and cement pressurization (digital or cement gun) yielded less radiolucencies at the bone-cement interface and improved prosthetic survival at 5 years (98% vs. 82%) when compared to manual irrigation alone.²⁵ The bony surfaces are kept clean and dry with suction and/or sponges (Fig. 37-1C). Most surgeons recognize that bleeding is minimized with maximal knee flexion. Still, the use of a tourniquet at this point in the procedure remains controversial and is left to surgeon preference. Some authors suggest using a tourniquet to minimize bleeding.²¹ However, Ejaz et al prospectively randomized 70 patients into a tourniquet and a nontourniquet group using radiostereometric analysis to evaluate implant motion. At 2 years there was no significant difference in tibial component migration between the two groups.²⁶ Generally, one cement mix allows sufficient time to apply cement to all three surfaces. (One or two 40-g bags are most commonly used based on prosthesis size and/or surgeon preference. In many cases, one bag of cement may be sufficient.) Digital compression is used with particular attention given to pressurizing cement into the posterior femoral condyles (Fig. 37-1D). After cement is applied directly to both femoral and tibial components, the implants are impacted into place, excess cement is removed, and the knee is brought out into full extension with a trial insert to enhance cement penetration (Fig. 37-1E). If indicated, the patella is similarly prepared, cemented, and clamped either first or last according to surgeon preference. Care is taken to avoid component malposition at this point, either flexion of the formal component or rotation of the tibial component. The knee is held
in place until the cement has hardened. Checking knee range of motion and laxity while the cement is hardening should be avoided as these procedures may disturb the bone-cement and, especially, the cement-prosthesis interface. All cement excrescences are removed. Again, adequate visualization is needed to remove any excess cement from about the posterior aspect of the femoral condyles and, especially, the posterior and lateral corner of the tibial component (Fig. 37-1F). A generous amount of irrigation with the jet lavage is used to remove the residual particulate debris prior to placing the tibial insert if a modular design is used (Fig. 37-1G). Postoperative radiographs are obtained either in the recovery room or at early postoperative period or both. They serve not only as a baseline to monitor any implant migration or signs of loosening but also provide unbiased and objective feedback on the surgeon’s cement technique (Fig. 37-2A and B).