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

Systematic Reviews and Meta-analyses and International Registry Data

Three systematic reviews and meta-analyses were reviewed. Beckmann et al[4] undertook a systematic review of studies from 1980 to 2010. Four studies on noncemented stems, 8 on hybrid fixation and 5 on fully cemented fixation were included. Outcomes of interest included survival of arthroplasty, rates of aseptic loosening, and clinical outcome. The included studies were mostly level of evidence III and IV. Most articles (12) had no control groups, had small number of cases, and involved a short follow-up. The authors concluded that no definitive statements could be drawn regarding optimal fixation technique and recommended randomized control trials to answer the question. Wang et al conducted a systematic review and meta-analysis of 17 observational studies from 1980 to 2014 to compare survivorship between fully cemented and hybrid fixation in rTKA. Their study included all articles from the review by Beckmann et al. Results including quantitative analysis showed similar outcomes in all variables studied (all-cause revision, revision for aseptic loosening, and infection) before and after a 60-month follow-up. They concluded that based on the available literature, no superiority of any type of fixation could be found.[44] Most of the reviewed articles had the same quality-related shortcomings noted in the review by Beckmann et al and were assessed to be moderate quality and of grade III to IV level of evidence. Neither review did a subgroup analysis of the three papers with control groups. Sheridan et al[45] in their review and meta-analysis included studies from 2010 with the aim of reflecting contemporary practice with improved proficiency in stem use in rTKA. Furthermore, they only included well-designed comparative studies. In contrast to the findings in the previous reviews, they reported that the hybrid technique had statistically significant lower all-cause failure rate, which is a composite of radiographic failure and all-cause re-revision. The all-cause re-revision, aseptic loosening rate, and radiographic failure showed a trend in favor of hybrid fixation, although not statistically significant. They concluded that the more recent literature supports a lower all-cause failure rate and a trend in favor of hybrid stems compared with all cemented stems regarding all-cause revision rates, revision for aseptic loosening, and radiographic failure.

Petursson et al reviewed the Norwegian Arthroplasty Registry by comparing both techniques in patients with re-revisions. They demonstrated statistically significant improvement in survival estimate for hybrid fixation (96.3%) compared with fully cemented stem (94.3%, relative risk 0.58, P = 0.001). They concluded that the hybrid technique showed a significant reduction in risk of revision.[46]