Cemented, cementless or hybrid fixation options in total knee arthroplasty for osteoarthritis and other non-traumatic diseases.
BACKGROUND
It is not clear which fixation of total knee arthroplasty obtains the best clinical, functional and radiographic results in people with osteoarthritis and other non-traumatic diseases, such as rheumatoid arthritis.


OBJECTIVE
To assess the benefits and harms of cemented, cementless and hybrid knee prostheses fixation techniques in participants with primary osteoarthritis (osteoarthritis following trauma was not included) and other non-traumatic diseases, such as rheumatoid arthritis.


METHODS
We searched CENTRAL (2011, issue 10), MEDLINE via PubMed, EMBASE, Current Controlled Trials, LILACS, The Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Health Technology Assessment Database and the Database of Abstracts of Reviews of Effectiveness, all from implementation to October 2011, along with handsearches of high-yield journals and reference lists of articles. No language restrictions were applied.


METHODS
Randomized controlled trials (RCTs) evaluating cemented, cementless and hybrid fixation. Participants included patients that were 18 years or older with osteoarthritis and other non-traumatic diseases who were undergoing primary total knee arthroplasty.


METHODS
Three authors independently selected the eligible trials, assessed the trial quality, risk of bias and extracted data. Researchers were contacted to obtain missing information.


RESULTS
Five RCTs and 297 participants were included in this review. Using meta-analysis on roentgen stereophotogrammetric analysis (RSA) we observed that cemented fixation of the tibial components demonstrated smaller displacement in relation to cementless fixation (with and without hydroxyapatite) after a follow-up of two years (maximum total point-motion, N = 167, two RCTs, mean difference (MD) = 0.52 mm, 95% confidence interval (CI) 0.31 to 0.74). However, the risk of future aseptic loosening with uncemented fixation was approximately half that of cemented fixation according to the arthroplasty instability classification (moderate quality as assessed by GRADE) inferred from RSA (N = 216, three RCTs, risk ratio (RR) = 0.47, 95% CI 0.24 to 0.92) with a 16% absolute risk difference between groups. The number needed to treat for an additional beneficial outcome (NNTB) to prevent future aseptic loosening was 7 (95% CI 5 to 44). There was a low risk of bias for RSA among the studies included. It was not possible to perform meta-analysis on patient-important outcomes, such as the survival rate of the implant (any change of a component), patient global assessments, functional measures, pain, health-related quality of life measures and adverse events. Almost all included studies recorded functional measures of Knee Society and Hospital for Special Surgery knee scores, but the authors of each study found no significant difference between the groups.


CONCLUSIONS
There was a smaller displacement of the cemented tibial component in relation to the cementless fixation in studies with osteoarthritis and rheumatoid arthritis participants who underwent primary total knee prosthesis with a follow-up of two years; however, the cemented fixation presented a greater risk of future aseptic loosening than cementless fixation.
Orthopaedic and Trauma Department, Universidade Federal de São Paulo, Rua Astarté, 297, São Paulo, São Paulo, Brazil, 03446-090.
Gilberto Yoshinobu
GY
Nakama
Maria Stella
MS
Peccin
Gustavo J M
GJ
Almeida
Ozório de Almeida
Ode A
Lira Neto
Antônio A B
AA
Queiroz
Ricardo Dizioli
RD
Navarro
D001172:Arthritis, Rheumatoid / Q000601:surgery*; D019645:Arthroplasty, Replacement, Knee / Q000379:methods*; D001672:Biocompatible Materials / Q000627:therapeutic use; D001843:Bone Cements / Q000627:therapeutic use*; D017886:Durapatite / Q000627:therapeutic use; D006801:Humans; D007720:Knee Prosthesis; D020370:Osteoarthritis, Knee / Q000601:surgery*; D011475:Prosthesis Failure / Q000209:etiology*; D059869:Radiostereometric Analysis / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D013997:Time Factors; D016896:Treatment Outcome
D001672:Biocompatible Materials; D001843:Bone Cements; D017886:Durapatite