New perspective in cementless total knee arthroplasty

Background: Total knee arthroplasty (TKA) remains a high-volume procedure with an increasing demand projected through 2030. While cemented fixation is the established gold standard, concerns regarding the polymethylmethacrylate interface and aseptic loosening of the tibial component have led to a resurgence of interest in cementless designs.

Objective: This review evaluates contemporary cementless TKA systems, focusing on advancements in biomaterials, tibial fixation strategies, and specific surgical techniques required to optimize biological osseointegration.

Key Points: Modern cementless implants utilize osteoconductive materials such as hydroxyapatite, porous tantalum, and 3D-printed titanium to facilitate bone ingrowth. Tibial component designs have evolved from simple pegs to complex configurations involving central keels and peripheral spikes to enhance primary stability and minimize micromotion. Clinical success depends on precise surgical execution, including the mitigation of thermal necrosis through cryocompression and cooled irrigation during osteotomy. Achieving a perfectly flat, symmetrical tibial resection and ensuring cortical contact for the baseplate are critical for long-term fixation. Furthermore, femoral components now incorporate specialized coatings, such as oxidized zirconium or titanium niobium nitride, to reduce ion release and polyethylene wear.

Conclusion: Innovations in porous surfaces and implant geometry have improved the primary stability and mid-term survivorship of cementless TKA. When combined with meticulous bone preparation and temperature control during surgery, these designs offer a viable alternative to cemented fixation, particularly for younger, active, or obese patient populations.