Which fixation method—cementless or cemented—is preferred for total knee arthroplasty?

Cemented vs Cementless Total Knee Arthroplasty

Either cemented or cementless fixation can be used for total knee arthroplasty, as both demonstrate equivalent clinical outcomes, complication rates, and revision rates. 1

Evidence-Based Recommendation

The American Academy of Orthopaedic Surgeons (AAOS) 2016 guidelines provide the definitive framework for this decision:

For Tibial Components

• Strong evidence supports using either cemented or cementless tibial component fixation due to similar functional outcomes, complication rates, and revision surgeries 1

For Both Femoral and Tibial Components

• Moderate evidence supports using either fully cemented or fully cementless components due to similar complication and revision rates 1

For Hybrid Fixation

• Moderate evidence supports either cementing all components or using hybrid fixation (cementless femoral component) due to similar functional outcomes and complication/revision rates 1

Recent High-Quality Research Findings

The most recent and highest quality study addressing mortality and morbidity outcomes is a 30-year bilateral comparison trial 2. This study demonstrated:

• No significant differences in Knee Society scores (92 vs 93 points)
• Equivalent revision rates: 3.8% cemented vs 4.8% cementless
• 30-year survival rates: 96.2% cemented vs 95.2% cementless
• Critical conclusion: Cementless TKA did not show superior survivorship compared to cemented TKA at 30+ years

A 2026 large database study of 11,064 propensity-matched patients 3 found at 5 years:

• Aseptic loosening: 0.9% cementless vs 1.2% cemented (p=0.165)
• All-cause revision: 3.7% cementless vs 3.8% cemented (p=0.781)
• 5-year survivorship: 99.1% for aseptic loosening, 96.3% for all-cause revision

Nuanced Considerations

Operative Differences

• Cementless TKA requires 8-15 minutes less operative time 4, 5
• Cemented TKA may provide better range of motion at 2 years (111° vs 104°) and fewer manipulations under anesthesia 5

Time-Dependent Outcomes

A 2024 meta-analysis 4 revealed an important temporal pattern:

• <5 years follow-up: Cementless showed better Knee Society scores (MD=-2.30, p=0.001)
• >5 years follow-up: Cemented showed better Knee Society scores (MD=2.79, p=0.003)

Osteolysis Risk

A 10-year randomized trial 6 found:

• Cemented fixation had higher rates of osteolysis (5 cases vs 2 cases)
• 80% of cemented osteolysis was tibial-sided
• This may relate to increased third-body wear from cement particles

Special Populations

• High BMI patients: Some evidence suggests cementless may reduce aseptic loosening revisions in obese patients 7
• Patients >70 years: Cementless achieves equivalent clinical scores to younger patients at 2 years 7

Common Pitfalls to Avoid

1. Don't assume cementless is "newer and better" - 30-year data shows no superiority 2
2. Don't delay surgery for fixation method selection - both are equivalent for patient-important outcomes
3. Don't use fixation method as the primary determinant - patient factors, bone quality, and surgeon experience matter more
4. Avoid rigid protocols - the AAOS explicitly states no single fixation option has strong advantage 1

Clinical Decision Algorithm

Choose based on:

1. Surgeon experience and preference - most critical factor given equivalent outcomes
2. Bone quality - poor bone stock may favor cemented fixation for immediate stability
3. Patient age and activity level - younger, more active patients may theoretically benefit from bone ingrowth potential of cementless
4. Operative efficiency needs - cementless saves 8-15 minutes operative time 4
5. Revision surgery concerns - both show equivalent long-term revision rates

The evidence does not support routine preference of one method over the other - this is a surgeon and patient preference decision within the context of equivalent long-term outcomes for mortality, morbidity, and quality of life 1, 2, 3.