International Orthopaedics

, Volume 39, Issue 1, pp 47–54 | Cite as

Comparison of different cement application techniques for tibial component fixation in TKA

  • Ulf J. SchlegelEmail author
  • Nicholas E. Bishop
  • Klaus Püschel
  • Michael M. Morlock
  • Katrin Nagel
Original Paper



Aseptic loosening of the tibial component remains a major cause for revision surgery in total knee arthroplasty (TKA). A stable initial fixation of the tibial implant has been suggested to reduce micromotion of the implant and could be decisive regarding its long-term performance. Different techniques for applying cement to the tibial surface have been described in the literature, with controversial results. No guidelines in favour of any particular approach are available.


In this study, we compared three commonly used cementing techniques (layered application, stem cementation, cement gun) with surface-only fingerpacking cementation following pulsed lavage (paired human tibiae, four groups, n = 24). Specimens underwent computed tomography scanning for three-dimensional analysis of cement penetration and mechanical testing for assessing interface strength.


Bone cement penetration decreased with increasing bone mineral density (BMD) (R 2 = 0.18, p = 0.023), while interface strength increased with BMD (R 2 = 0.56, p < 0.001). No significant effect of cementation techniques on cement penetration (p ≥ 0.069) or interface strength (p = 0.180) was found in any group.


Adequate surface preparation using pulsed lavage and copious drying of the tibial surface appears to be of overruling importance, thus limiting the effect of any particular technique applied to improve implant fixation. This study emphasises the fundamental importance of surface preparation and pulsed lavage in TKA.


Total knee arthroplasty Cementing technique Surface cementation Stem cementation Bone cement penetration Gun cementing Pulsed lavage 



Financial support for this study was received from DePuy Orthopaedics.


  1. 1.
    Arsoy D, Pagnano MW, Lewallen DG, Hanssen AD, Sierra RJ (2013) Aseptic tibial debonding as a cause of early failure in a modern total knee arthroplasty design. Clin Orthop Relat Res 471:94–101PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Bauze AJ, Costi JJ, Stavrou P, Rankin WA, Hearn TC, Krishnan J, Slavotinek JP (2004) Cement penetration and stiffness of the cement-bone composite in the proximal tibia in a porcine model. J Orthop Surg (Hong Kong) 12:194–198Google Scholar
  3. 3.
    Bert JM, McShane M (1998) Is it necessary to cement the tibial stem in cemented total knee arthroplasty? Clin Orthop Relat Res:73–78Google Scholar
  4. 4.
    Breusch SJ, Norman TL, Schneider U, Reitzel T, Blaha JD, Lukoschek M (2000) Lavage technique in total hip arthroplasty: jet lavage produces better cement penetration than syringe lavage in the proximal femur. J Arthroplasty 15:921–927PubMedCrossRefGoogle Scholar
  5. 5.
    Cawley DT, Kelly N, McGarry JP, Shannon FJ (2013) Cementing techniques for the tibial component in primary total knee replacement. Bone Joint J 95-B:295–300PubMedCrossRefGoogle Scholar
  6. 6.
    Clarius M, Hauck C, Seeger JB, James A, Murray DW, Aldinger PR (2009) Pulsed lavage reduces the incidence of radiolucent lines under the tibial tray of Oxford unicompartmental knee arthroplasty: pulsed lavage versus syringe lavage. Int Orthop 33:1585–1590PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Dixon MC, Brown RR, Parsch D, Scott RD (2005) Modular fixed-bearing total knee arthroplasty with retention of the posterior cruciate ligament. A study of patients followed for a minimum of fifteen years. J Bone Joint Surg Am 87:598–603PubMedCrossRefGoogle Scholar
  8. 8.
    Efe T, Figiel J, Sibbert D, Fuchs-Winkelmann S, Tibesku CO, Timmesfeld N, Paletta JR, Skwara A (2011) Revision of tibial TKA components: bone loss is independent of cementing type and technique: an in vitro cadaver study. BMC Musculoskelet Disord 12:6PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Fetzer GB, Callaghan JJ, Templeton JE, Goetz DD, Sullivan PM, Kelley SS (2002) Posterior cruciate-retaining modular total knee arthroplasty: a 9- to 12-year follow-up investigation. J Arthroplasty 17:961–966PubMedCrossRefGoogle Scholar
  10. 10.
    Fischer CA, Kaszap B, Drexler C, Lehner B, Clarius M (2012) Cemented total hip arthroplasty in Germany - update 2010. Z Orthop Unfall 150:309–317PubMedGoogle Scholar
  11. 11.
    Furnes O, Espehaug B, Lie SA, Vollset SE, Engesaeter LB, Havelin LI (2002) Early failures among 7,174 primary total knee replacements: a follow-up study from the Norwegian Arthroplasty Register 1994–2000. Acta Orthop Scand 73:117–129PubMedCrossRefGoogle Scholar
  12. 12.
    Galasso O, Jenny JY, Saragaglia D, Miehlke RK (2013) Full versus surface tibial baseplate cementation in total knee arthroplasty. Orthopedics 36:e151–e158PubMedCrossRefGoogle Scholar
  13. 13.
    Gebert de Uhlenbrock A, Puschel V, Puschel K, Morlock MM, Bishop NE (2012) Influence of time in-situ and implant type on fixation strength of cemented tibial trays - a post mortem retrieval analysis. Clin Biomech (Bristol, Avon) 27:929–935CrossRefGoogle Scholar
  14. 14.
    Herberts P, Malchau H (2000) Long-term registration has improved the quality of hip replacement: a review of the Swedish THR register comparing 160,000 cases. Acta Orthop Scand 71:111–121PubMedCrossRefGoogle Scholar
  15. 15.
    Hernandez-Vaquero D, Garcia-Sandoval MA, Fernandez-Carreira JM, Gava R (2008) Influence of the tibial stem design on bone density after cemented total knee arthroplasty: a prospective seven-year follow-up study. Int Orthop 32:47–51PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Hofmann AA, Goldberg TD, Tanner AM, Cook TM (2006) Surface cementation of stemmed tibial components in primary total knee arthroplasty: minimum 5-year follow-up. J Arthroplasty 21:353–357PubMedCrossRefGoogle Scholar
  17. 17.
    Jaeger S, Seeger JB, Schuld C, Bitsch RG, Clarius M Tibial Cementing in UKA: A Three-Dimensional Analysis of the Bone Cement Implant Interface and the Effect of Bone Lavage. J ArthroplastyGoogle Scholar
  18. 18.
    Janssen D, Mann KA, Verdonschot N (2008) Micro-mechanical modeling of the cement-bone interface: the effect of friction, morphology and material properties on the micromechanical response. J Biomech 41:3158–3163PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Jones CW, Lam LO, Butler A, Wood DJ, Walsh WR (2009) Cement penetration after patella venting. Knee 16:50–53PubMedCrossRefGoogle Scholar
  20. 20.
    Kalteis T, Pforringer D, Herold T, Handel M, Renkawitz T, Plitz W (2007) An experimental comparison of different devices for pulsatile high-pressure lavage and their relevance to cement intrusion into cancellous bone. Arch Orthop Trauma Surg 127:873–877PubMedCrossRefGoogle Scholar
  21. 21.
    Kim YH, Park JW, Lim HM, Park ES (2014) Cementless and cemented total knee arthroplasty in patients younger than fifty five years. Which is better? Int Orthop 38:297–303PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Kopec M, Milbrandt JC, Duellman T, Mangan D, Allan DG (2009) Effect of hand packing versus cement gun pressurization on cement mantle in total knee arthroplasty. Can J Surg 52:490–494PubMedCentralPubMedGoogle Scholar
  23. 23.
    Kopec M, Milbrandt JC, Kohut N, Kern B, Allan DG (2009) Effect of bone cement viscosity and set time on mantle area in total knee arthroplasty. Am J Orthop (Belle Mead NJ) 38:519–522Google Scholar
  24. 24.
    Krause WR, Krug W, Miller J (1982) Strength of the cement-bone interface. Clin Orthop Relat Res:290–299Google Scholar
  25. 25.
    Luring C, Perlick L, Trepte C, Linhardt O, Perlick C, Plitz W, Grifka J (2006) Micromotion in cemented rotating platform total knee arthroplasty: cemented tibial stem versus hybrid fixation. Arch Orthop Trauma Surg 126:45–48PubMedCrossRefGoogle Scholar
  26. 26.
    Lutz MJ, Halliday BR (2002) Survey of current cementing techniques in total knee replacement. ANZ J Surg 72:437–439PubMedCrossRefGoogle Scholar
  27. 27.
    Lutz MJ, Pincus PF, Whitehouse SL, Halliday BR (2009) The effect of cement gun and cement syringe use on the tibial cement mantle in total knee arthroplasty. J Arthroplasty 24:461–467PubMedCrossRefGoogle Scholar
  28. 28.
    Maistrelli GL, Antonelli L, Fornasier V, Mahomed N (1995) Cement penetration with pulsed lavage versus syringe irrigation in total knee arthroplasty. Clin Orthop Relat Res:261–265Google Scholar
  29. 29.
    Mann KA, Miller MA, Pray CL, Verdonschot N, Janssen D (2012) A new approach to quantify trabecular resorption adjacent to cemented knee arthroplasty. J Biomech 45:711–715PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Park SH, Silva M, Park JS, Ebramzadeh E, Schmalzried TP (2001) Cement-cement interface strength: influence of time to apposition. J Biomed Mater Res 58:741–746PubMedCrossRefGoogle Scholar
  31. 31.
    Parsch D, Kruger M, Moser MT, Geiger F (2009) Follow-up of 11–16 years after modular fixed-bearing TKA. Int Orthop 33:431–435PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Peters CL, Craig MA, Mohr RA, Bachus KN (2003) Tibial component fixation with cement: full- versus surface-cementation techniques. Clin Orthop Relat Res:158–168Google Scholar
  33. 33.
    Raiss P, Pape G, Kleinschmidt K, Jager S, Sowa B, Jakubowitz E, Loew M, Bruckner T, Rickert M (2011) Bone cement penetration pattern and primary stability testing in keeled and pegged glenoid components. J Should Elb Surg 20:723–731CrossRefGoogle Scholar
  34. 34.
    Reilly D, Walker PS, Ben-Dov M, Ewald FC (1982) Effects of tibial components on load transfer in the upper tibia. Clin Orthop Relat Res:273–282Google Scholar
  35. 35.
    Rossi R, Bruzzone M, Bonasia DE, Ferro A, Castoldi F (2010) No early tibial tray loosening after surface cementing technique in mobile-bearing TKA. Knee Surg Sports Traumatol ArthroscGoogle Scholar
  36. 36.
    Ryd L, Hansson U, Blunn G, Lindstrand A, Toksvig-Larsen S (1999) Failure of partial cementation to achieve implant stability and bone ingrowth: a long-term roentgen stereophotogrammetric study of tibial components. J Orthop Res 17:311–320PubMedCrossRefGoogle Scholar
  37. 37.
    Saari T, Li MG, Wood D, Nivbrant B (2009) Comparison of cementing techniques of the tibial component in total knee replacement. Int Orthop 33:1239–1242PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Schlegel UJ, Puschel K, Morlock MM, Nagel K (2014) An in vitro comparison of tibial tray cementation using gun pressurization or pulsed lavage. Int Orthop 38:967–971PubMedCrossRefGoogle Scholar
  39. 39.
    Schlegel UJ, Siewe J, Delank KS, Eysel P, Puschel K, Morlock MM, de Uhlenbrock AG (2011) Pulsed lavage improves fixation strength of cemented tibial components. Int Orthop 35:1165–1169PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Seki T, Bourgeault ST, Chareancholvanich K, Lew W, Bechtold JE, Gustilo RB (1997) Does a central stem affect bone strain and the stability of a cemented tibial tray in primary and revision TKA? Trans Orthop Res Soc 22:6356Google Scholar
  41. 41.
    Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM (2002) Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res:7–13Google Scholar
  42. 42.
    Vanlommel J, Luyckx JP, Labey L, Innocenti B, De Corte R, Bellemans J (2010) Cementing the Tibial Component in Total Knee Arthroplasty Which Technique is the Best? J ArthroplastyGoogle Scholar
  43. 43.
    Victor J, Ghijselings S, Tajdar F, Van Damme G, Deprez P, Arnout N, Van Der Straeten C (2014) Total knee arthroplasty at 15–17 years: does implant design affect outcome? Int Orthop 38:235–241PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Walker PS, Greene D, Reilly D, Thatcher J, Ben-Dov M, Ewald FC (1981) Fixation of tibial components of knee prostheses. J Bone Joint Surg Am 63:258–267PubMedGoogle Scholar
  45. 45.
    Walker PS, Soudry M, Ewald FC, McVickar H (1984) Control of cement penetration in total knee arthroplasty. Clin Orthop Relat Res:155–164Google Scholar

Copyright information

© SICOT aisbl 2014

Authors and Affiliations

  • Ulf J. Schlegel
    • 1
    Email author
  • Nicholas E. Bishop
    • 2
  • Klaus Püschel
    • 3
  • Michael M. Morlock
    • 2
  • Katrin Nagel
    • 2
  1. 1.Department of Orthopaedic and Trauma SurgeryUniversity of HeidelbergHeidelbergGermany
  2. 2.Biomechanics Section, TUHH Hamburg University of TechnologyHamburgGermany
  3. 3.Institute of Legal MedicineUniversity of Hamburg-EppendorfHamburgGermany

Personalised recommendations