At the present time, total knee surgeons are still faced with the decision concerning the type of fixation that they will rely upon for knee arthroplasty. The two camps have well-established theories. Cementless fixation has long-term results that are equal to those of the cemented prostheses. Studies out to 15 years and now approaching 20 years clearly document reliable results.27-30 The well-ingrown total knee should remain fixed for a lifetime with just the possibility of polyethylene wear as the only consequence. The major problem with the cementless technology is the early loosening. Almost all studies report a 1% incidence most commonly on the tibial side. The loosening may be the result of surgical failure to establish full, acceptable surface contact. If this is the case, improvement in surgical technique should help to decrease loosening rates. There are new cutting instruments (such as milling devices) and guides that may improve surgical accuracy and increase contact. However, the loosening can be a result of micromotion at the interface that may be unavoidable if one expects to move the joint early after surgery to maintain range of motion. In this scenario, loosening may represent a persistent problem.
The cemented prostheses also have an excellent longterm history with similar 15- to 20-year results. The early loosening rate is well below 1% and is a rare occurrence. However, there is the lingering question concerning ultimate failure of the cement mantles. Thus far, this ultimate failure rate has not presented itself at the 15- to 20-year mark. Some investigators believe that the failure is inevitable. However, the surgeon must presently choose between a well-known early loosening rate with the cementless design or a theoretical concern for the future that has not as yet presented itself as a significant problem.
In light of this discussion, the author remains dedicated to cement fixation with an open eye toward the improvement of the cementless technology.
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