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Cementless unicompartmental knee replacement achieves better ten-year clinical outcomes than cemented: a systematic review

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The aim of this study was to report and compare the long-term revision rate, revision indications and patient reported outcome measures of cemented and cementless unicompartmental knee replacements (UKR).

Methods

Databases Medline, Embase and Cochrane Central of Controlled Trials were searched to identify all UKR studies reporting the ≥ 10 year clinical outcomes. Revision rates per 100 component years [% per annum (% pa)] were calculated by fixation type and then, subgroup analyses for fixed and mobile bearing UKRs were performed. Mechanisms of failure and patient reported outcome measures are reported.

Results

25 studies were eligible for inclusion with a total of 10,736 UKRs, in which there were 8790 cemented and 1946 cementless knee replacements. The revision rate was 0.73% pa (CI 0.66–0.80) and 0.45% pa (CI 0.34–0.58) per 100 component years, respectively, with the cementless having a significantly (p < 0.001) lower overall revision rate. Therefore, based on these studies, the expected 10-year survival of cementless UKR would be 95.5% and cemented 92.7%. Subgroup analysis revealed this difference remained significant for the Oxford UKR (0.37% pa vs 0.77% pa, p < 0.001), but for non-Oxford UKRs there were no significant differences in revision rates of cemented and cementless UKRs (0.57% pa vs 0.69% pa, p = 0.41). Mobile bearing UKRs had significantly lower revision rates than fixed bearing UKRs in cementless (p = 0.001), but not cemented groups (p = 0.13). Overall the revision rates for aseptic loosening and disease progression were significantly lower (p = 0.02 and p = 0.009 respectively) in the cementless group compared to the cemented group (0.06 vs 0.13% pa and 0.10 vs 0.21% pa respectively).

Conclusions

Cementless fixation had reduced long-term revision rates compared to cemented for the Oxford UKR. For the non-Oxford UKRs, the revision rates of cementless and cemented fixation types were equivalent. Therefore, cementless UKRs offer at least equivalent if not lower revision rates compared to cemented UKRs.

Level of evidence

III.

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Abbreviations

AKSS-O:

American Knee Society Score (Objective)

AKSS-F:

American Knee Society Score (Functional)

CENTRAL:

Cochrane Central of Controlled Trials

CI:

Confidence interval

HSS:

Hospital for Special Surgery knee score

KSS:

Knee Society Score

MINOR:

Methodological index for evaluation of non-randomised studies

OKS:

Oxford Knee Score

pa:

Per annum

PROM:

Patient-reported outcome measure

PRIMSA:

Preferred reporting items for systematic reviews and meta-analyses

TKR:

Total knee replacement

WOMAC:

Western Ontario and McMaster universities arthritis index

UKR:

Unicompartmental knee replacement

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Authors and Affiliations

  1. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK

    Hasan R. Mohammad, Garrett S. Bullock, James A. Kennedy, Stephen J. Mellon, David Murray & Andrew Judge

  2. Musculoskeletal Research Unit, Bristol Medical School, Level 1 Learning and Research Building, Southmead Hospital, University of Bristol, Westbury-On-Trym, Bristol, BS10 5NB, UK

    Hasan R. Mohammad & Andrew Judge

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Contributions

HRM, GSB, JAK, SJM, AJ and DM designed the study. HRM and GSB collected and analysed the data with statistical support from AJ and DM. HRM, GSB, JAK, SJM, AJ and DM helped with data interpretation. HRM wrote the initial manuscript draft which was then revised appropriately by all authors prior to submission. All authors were involved in the study design, analysis, interpretation of findings and writing of the submitted manuscript.

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Correspondence to Hasan R. Mohammad.

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The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund, foundation, educational institution, or other non-profit organisation with which one or more of the authors are associated. This research did not receive any specific grant from funding agencies in the public, commercial or not for profit sectors. HRM was supported by Royal College of Surgeons Research Fellowship and the University of Oxford’s Henni Mester scholarship. AJ was supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

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Appendices

Appendix

Database searches

MEDLINE search

  1. 1.

    Knee/ or exp Knee Joint/ or Osteoarthritis, Knee/

  2. 2.

    knee*.tw.

  3. 3.

    1 or 2

  4. 4.

    Knee Prosthesis/ or Arthroplasty, Replacement, Knee/

  5. 5.

    (knee* and (arthroplast* or implant* or replace* or prosthe* or endoprosthe*)).tw.

  6. 6.

    4 or 5

  7. 7.

    "Prostheses and Implants"/

  8. 8.

    3 and 7

  9. 9.

    6 or 8

  10. 10.

    Cementation/

  11. 11.

    Bone Cements/

  12. 12.

    exp Hydroxyapatites/

  13. 13.

    (cement* or uncement* or hydroxyapatite or durapatite or hybrid or porous* or coat* or press-fit* or fixation or implant*).tw.

  14. 14.

    10 or 11 or 12 or 13

  15. 15.

    9 and 14

  16. 16.

    15

  17. 17.

    limit 16 to english language

  18. 18.

    Osteoarthritis, Knee/

  19. 19.

    osteoarthr*.tw.

  20. 20.

    18 or 19

  21. 21.

    17 and 20

EMBASE search

  1. 1.

    knee/

  2. 2.

    knee*.tw.

  3. 3.

    1 or 2

  4. 4.

    exp knee arthroplasty/

  5. 5.

    exp knee prosthesis/

  6. 6.

    (knee* adj2 (arthroplast* or implant* or replace* or prosthe* or endoprosthe*)).tw.

  7. 7.

    4 or 5 or 6

  8. 8.

    exp implantation/

  9. 9.

    3 and 8

  10. 10.

    7 or 9

  11. 11.

    cementation/

  12. 12.

    hydroxyapatite/

  13. 13.

    (cement* or uncement* or hydroxyapatite or durapatite or hybrid or porous* or coat* or press-fit* or fixation or implant*).tw.

  14. 14.

    11 or 12 or 13

  15. 15.

    knee osteoarthritis/

  16. 16.

    (knee and osteoarthr*).ti,ab.

  17. 17.

    15 or 16

  18. 18.

    10 and 14 and 17

  19. 19.

    18

  20. 20.

    limit 19 to english language

CENTRAL search

  1. 1.

    MeSH descriptor: [Knee] explode all trees

  2. 2.

    MeSH descriptor: [Knee Joint] explode all trees

  3. 3.

    knee*

  4. 4.

    #1 OR #2 OR #3

  5. 5.

    MeSH descriptor: [Arthroplasty, Replacement, Knee] explode all trees

  6. 6.

    MeSH descriptor: [Knee Prosthesis] explode all trees

  7. 7.

    (knee* and (arthroplast* or implant* or replace* or prosthe* or endoprosthe*))

  8. 8.

    #5 OR #6 OR #7

  9. 9.

    MeSH descriptor: [Prostheses and Implants] explode all trees

  10. 10.

    #4 AND #9

  11. 11.

    #8 OR #10

  12. 12.

    MeSH descriptor: [Cementation] explode all trees

  13. 13.

    MeSH descriptor: [Bone Cements] explode all trees

  14. 14.

    MeSH descriptor: [Durapatite] explode all trees

  15. 15.

    (cement* or uncement* or hydroxyapatite or durapatite or hybrid or porous* or coat* or press-fit* or fixation or implant*)

  16. 16.

    #12 OR #13 OR #14 OR #15

  17. 17.

    osteoarthr*

  18. 18.

    #11 AND #16 AND #17

See Tables 7 and 8.

Table 7 The calculated revision rates per 100 component years for each for the included studies
Full size table
Table 8 The revision indications for the included studies in the mechanisms of failure analysis
Full size table

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Mohammad, H.R., Bullock, G., Kennedy, J. et al. Cementless unicompartmental knee replacement achieves better ten-year clinical outcomes than cemented: a systematic review. Knee Surg Sports Traumatol Arthrosc 29, 3229–3245 (2021). https://doi.org/10.1007/s00167-020-06091-5

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