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Loss of Cement-bone Interlock in Retrieved Tibial Components from Total Knee Arthroplasties

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Clinical Orthopaedics and Related Research®

A CORR Insights® to this article was published on 26 September 2013



Aseptic loosening continues to be a short- and long-term complication for patients with cemented TKAs. Most studies to this point have evaluated tibial component fixation via radiographic changes at the implant-bone interface and quantification of component migration; direct assessment of morphologic features of the interface from functioning TKAs may provide new information regarding how TKAs function and are fixed to bone.


In a postmortem retrieval study, we asked: (1) What are the morphologic features at the cement-trabecular bone interface in retrieved tibial components? (2) Do constructs with greater time in service have less cement-trabecular bone interlock? (3) Do constructs with more estimated initial interlock sustain more interlock with in vivo service?


Fourteen postmortem retrieved tibial components with time in service from 0 to 20 years were sectioned and imaged at high resolution, and the current contact fraction, estimated initial interdigitation depth, current interdigitation depth, and loss of interdigitation depth were quantified at the cement-bone interface. Estimated initial interdigitation depth was calculated from the initial mold shape of the cement mantle that forms around the individual trabeculae at the time of surgery. Loss of interdigitation depth was the difference between the initial and current interdigitation depth.


There was resorption of trabeculae that initially interlocked with the cement in the postmortem retrievals as evidenced by the differences between current interdigitation and the estimated original interdigitation. The current contact fraction (r2 = 0.54; p = 0.0027) and current interdigitation depth (r2 = 0.33; p = 0.033) were less for constructs with longer time in service. The current contact fraction for implants with 10 or more years in service (6.2%; 95% CI, 4.7%–7.7%) was much less than implants with less than 10 years in service (22.9%; 95% CI, 8.9%–37%). Similarly, the current interdigitation depth for implants with 10 or more years in service (0.4 mm; 95% CI, 0.27–0.53 mm) was much less than implants with less than 10 years in service (1.13 mm; 95% CI, 0.48–1.78 mm). The loss of interdigitation depth had a strong positive relationship with time in service (r2 = 0.74; p < 0.001). Using a two-parameter regression model, constructs with more initial interdigitation depth had greater current interdigitation depth (p = 0.011), but constructs with more time in service also had less current interdigitation depth (p = 0.008).


The cement-trabecular bone interlock obtained initially appears to diminish with time with in vivo service by resorption of the trabeculae in the cement interlock region.

Clinical Relevance

Our study supports the surgical concept of obtaining sufficient initial cement interlock (approximately 3 mm), with the acknowledgment that there will be loss of interlock with time with in vivo service.

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We thank Megan Oest PhD for assistance with specimen staining and Joseph Battaglia BS for assistance with specimen sectioning.

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Correspondence to Kenneth A. Mann PhD.

Additional information

The institution of one or more of the authors (MAM, JRG, KAM) has received, during the study period, funding from the National Institutes of Health (NIH AR42017). One of the authors certifies that he (THI), or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount of USD (USD 10,000 to USD 100,000), from Stryker Orthopaedics (Mahwah, NJ, USA).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at SUNY Upstate Medical University, Syracuse, NY, USA.

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Miller, M.A., Goodheart, J.R., Izant, T.H. et al. Loss of Cement-bone Interlock in Retrieved Tibial Components from Total Knee Arthroplasties. Clin Orthop Relat Res 472, 304–313 (2014).

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