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

Hybrid Fixation

The hybrid method of fixation in rTKA is achieved using press-fit diaphyseal stems in conjunction with cementing the epiphyseal and metaphyseal regions up to the meta-diaphyseal junction of the implant[7] (Figure 1).

Figure 1.

Radiograph showing hybrid fixation technique of stemmed rTKA. A, AP view. B, Lateral view. rTKA = revision total knee arthroplasty.

The hybrid technique has some advantages over the fully cemented method (Table 1) including relative ease of removal and preservation of bone stock if additional revision is required. Wood et al[8] in 2009 explained that because noncemented stems are not intended to produce ingrowth or ongrowth, stem extraction, when necessary, is a more bone-conserving procedure. In the presence of cement lock caused by an offset implant, removal of hybrid stem may become very difficult. Other advantages include the ability to achieve mechanical alignment using the intramedullary anatomic axis and offloading interface stresses.[9] It also allows fixation distal to the area of metaphyseal bone loss and provides favorable support for allograft prosthetic composites when used. The available literature shows that adequate canal fill of the stems is required to attain adequate fixation.[10] Hybrid technique requires maximal canal fill to attain a solid press fit.[10] When used appropriately, noncemented stems have demonstrated lower rates of radiographic loosening when compared with cemented stems.[11]

Hybrid technique exhibit certain disadvantages such as increased risk of an intraoperative periprosthetic fracture and stress shielding.[12] Press-fit stems also have a 20% reported incidence of end of stem pain, which may affect overall functional outcomes.[13]

Fehring et al[14] reported a comparative analysis of stem fixation in 475 rTKAs and showed that 29% of press-fit metaphyseal engaging noncemented stems were unstable compared with 7% of cemented stems according to a radiological analysis. Hybrid stems in this study were metaphyseal engaging and did not engage the diaphysis. This also appears to be responsible for the poor results in the study by Shannon et al.[15] Other studies where longer diaphyseal engaging stems were used in hybrid fixation have demonstrated excellent outcomes at mid-term follow-ups (Table 2). Hybrid fixation technique remains an effective option in rTKA.[8,15–19]