Cemented Versus Hybrid Technique of Fixation of the Stemmed Revision Total Knee Arthroplasty: A Literature Review

A Literature Review

Charles Ayekoloye, MD, FRCS; Mehran Radi, MD; David Backstein, MD, MED, FRCSC; Moayad Abu Qa'oud, MD


J Am Acad Orthop Surg. 2022;30(9):e703-e713. 

In This Article

Abstract and Introduction


Stems are required during revision total knee arthroplasty to bypass damaged periarticular bone and transfer stress to healthier diaphyseal bone. The mode of stem fixation, whether fully cemented or hybrid, remains controversial. Improvements in surgical technique and implant and instrument technology have improved our ability to deal with many of the challenges of revision total knee arthroplasty. Recent publications that reflect contemporary practice has prompted this review of literature covering the past 20 years to determine whether superiority of one fixation mode over the other can be demonstrated. We reviewed single studies of each type of fixation, studies directly comparing both types of fixation, systematic reviews, international registry data, and studies highlighting the pros and cons of each mode of stem fixation. Based on the available literature, we conclude that using both methods of fixation carries comparable outcomes with marginal superiority of the hybrid fixation method, which is of nonstatistical significance, although on an individual case basis, all fixation methods should be kept in mind and the appropriate method implemented when suitable.


Total knee arthroplasty (TKA) results in excellent pain relief, restoration of function, and improvement in quality of life with up to 95% 15-year survival.[1] As the proportion of the elderly population rises due to increasing life expectancy and with many wishing to remain active for longer, the demand for both primary and revision total knee arthroplasty (rTKA) will continue to rise. Indeed, projections show that demand for rTKA will increase by 601% between 2005 and 2030, as that for primary TKA increases by 673% in the same period in the United States.[2]

Revision TKA can be a challenging operation. An issue that surgeons are often faced with is severely compromised metaphyseal bony support. Using stemmed implants in rTKA is necessary to bypass the periarticular bone and transfer load to the stronger diaphyseal bone.[3] Stable stem fixation is a crucial goal of rTKA and whether to choose cemented or press-fit stems remains controversial.[4]

Recently, the concept of zonal fixation has aided our understanding of the requirements for durable reconstruction in rTKA.[5] In addition, the introduction and use of porous metal cones and metaphyseal sleeves has helped provide a means of more consistently achieving successful and lasting biologic reconstruction of large metaphyseal bone defects.[6] These void fillers, combined with stems, have resulted in more secure two-zone fixation, a requirement for long-term durable rTKA.[5]

Most of the more recent literature compare the hybrid technique with the fully cemented technique.

This study reviewed the literature of the past 20 years, including the biomechanics of stem fixation, clinical results of the hybrid, and the fully cemented methods of stem fixation. The goal was to determine whether superiority in the performance of either technique can be demonstrated and provide guidance on appropriate use of either technique in rTKA based on recent available knowledge.