Cemented and Cementless Knee Replacement

Total knee replacement is one of the most commonly performed joint replacement surgeries. Total knee arthroplasty (TKA) is a surgical procedure to replace diseased ends of the knee joint with prosthetic materials. Traditionally knee replacement surgery has been performed used cemented prosthesis. Recently however a number of cementless total knee replacement surgeries are being done with excellent results. 

There has been a constant debate between cemented and cementless knee replacement. Compared to cemented prosthesis cementless prostheses have been proposed to have long term survivorship. Cementless implants have a biological fixation with bone growth. 

Knee Anatomy & Arthritis

The knee joint is formed by the lower end of the thigh bone and the upper end of the shinbone. The kneecap (patella) sits in a groove between the distal end of the thigh bone (femur). A proper alignment between all the bones it necessary for optimal function of the joint. 

The articulating cartilage is a shiny glistening white fibrous tissue present on the ends of the bones forming the joint. The cartilage not only acts as a cushion for the joint but also helps in smooth gliding movements of the knee. The medial and lateral meniscus are small pads of tissues present between the femur and tibia. The menisci provide stability and cushion against impacts.

There are various ligaments supporting the knee to prevent laxity during joint motion. The anterior cruciate ligament and the posterior cruciate ligament provide stability mainly in the front and the back. The medial collateral ligament and the lateral collateral ligament provides stability on the sides of the knee joint. 

Arthritis remains the most common cause of knee pain in the elderly requiring replacement. Arthritis could be due to degenerative wear and tear known as osteoarthritis. Inflammatory causes of arthritis are rheumatoid arthritis and psoriatic arthritis.

Injury or trauma to the structures forming the knee joint can also cause early arthritic changes in the knee. Malalignment of the knee joint or the kneecap can also result in arthritis. Instability due to the laxity of the ligaments may also result in early arthritic changes in the knee joint.

Total knee replacement is done when all other conservative forms of management have been exhausted. There is an increasing trend of total knee replacement owing to the success of the surgery. Patients in all age groups have had a total knee replacement with excellent results and early return to daily activities.

Cemented Total Knee Replacement

After the patients are medically cleared for surgery and received appropriate anesthesia, the knee joint is opened from the front. The diseased segments of the bones forming the joint are removed. Using cutting guides, bone cuts made in the femur, tibia and the patella. 

Cemented TKA

Cemented TKA

After thoroughly washing the cut segments, acrylic bone cement is applied to the implants and the bone segments. The implants are then fixed to the prepared bed on the bone. 

A plastic high-quality polyethylene space is attached to the tibial component to reduce friction between the implants. The acrylic cement hardens quickly providing immediate fixation.

Constrained polyethylene insert

A constrained polyethylene insert may be used in a knee with ligament instability on the sides. The tall and wide tibial post on the polyethylene insert ensures rotational and small side to side stability. The insert is made of highly cross-linked polyethylene which is resistant to wear and tear. The tibial post fits in front of the femoral cam providing stability.

Femoral Component (posterior stabilized)

The posterior stabilized femoral component involves sacrificing the posterior cruciate ligament during surgery. The function of the posterior cruciate ligament is duplicated by the femoral cam and the tibial post mechanism.

Modular femoral component

The non constrained posterior stabilized polyethylene insert has a tibial post that works along with femoral cam to provide femoral rollback. The polyethylene is highly cross linked and treated with anti-oxidants to prevent wear and particles.

Modular femoral stem

The femoral stem fits in a modular femoral component and is used in revision surgery to achieve greater stability of the prosthesis. The stem is not cemented while the modular femoral component is cemented in the lower thigh bone.

Modular femoral component

Modular tibial component with bone augments (metal wedges)

Similar to modular femoral component, a modular tibial component is used in revision knee replacement. The modular components allow attachment of stem and bone augments (metal cones/wedges) to achieve stable fixation and stabilize the prosthetic knee in all ranges of motion.

Cementless Total Knee Replacement

The surgical steps remain the same, however, the femoral and tibial components are press-fitted on the bones. The implants are specially designed to have a porous surface to allow for bone growth. The patella is cemented due to high rates of failure with cementless fixation. 

The bone cuts have to be accurate in case of cementless tka for the implant to be press-fitted. Screws or pegs are used for additional fixation in case of the tibial component. 

Advantages & Potential Drawbacks of Cemented Fixation

The acrylic cement dries very quickly providing immediate fixation. The cemented implants have been in use for many years now with a significant date on their success. On average, the cemented total knee prosthesis lasts for 15-20 years or more. 

The cement provides excellent fixation in the case of osteoporotic or weak bones. Cemented implants provide a better fixation in old, obese, osteoporosis, cancer patients with poor bone quality.

Over a period of time, the cement which forms a layer between the bone and the implant may become loose. In younger patients, a high amount of stress on the joint may also cause loosening of the bone cement. 

Once the cement begins to come loose, the implant loosens and may rub against the bone causing pain. Loosened implants frequently require revision surgery. The revision surgery is also complicated by the presence of cement. 

The cement may also cause third body wear. Small fragments of the cement may break in and rub against the implants. The particles may also lead to inflammation as the body tries to remove the debris. 

This may lead to a condition known as osteolysis  as the inflammatory cells may also remove the bone around the implant. The loosened implant may again require revision. 

As the bone cement hardens, it releases a lot of thermal energy. The heat may damage the underlying bone surface causing thermal necrosis. Additionally, the process of cementing may lead to increased chances of fat embolism. 

Advantages & Disadvantages of Cementless Fixation

Cementless implants are press-fitted into the bone, as they have a special porous surface to stimulate bone growth. The bone growth happens over a long period of time thus not providing immediate fixation. As they promote biological fixation, they are proposed to have longer survivorship. 

The limitations of cement fixation are not present in cementless fixation. The cementless fixation although needs good bone stock. Young patients with good bone metabolism are the ideal candidate for cementless fixation. 

However, cementless fixation requires accurate bone cuts to prevent any gaps between the implant and the bone surface. The surgery time for cementless fixation is significantly less than the cemented fixation. The chances of osteolysis are reduced in cementless fixation but the microscopic particles from the implant may still lead to osteolysis.

The revision surgery for cementless implants is much easier due to the availability of good bone stock. Although there are fewer problems of cementless fixation they have in use only recently. The long term advantages and drawbacks are yet not fully understood. 

With the advancement in implant materials, there is a growing interest in the cementless fixation of knee implants. Hybrid fixations have also been done where the femoral component is fixed cementless and the tibia is fixed with bone cement. 

Complications of Joint Replacement

As with any surgery, there may be potential complications of joint replacement surgery. There may be medical complications including stroke, heart attack, pneumonia or urinary tract infections. During the surgery, there may be complications such as fractures, nerve damage, blood vessel damage, shortening, instability or dislocation. 

After the surgery, during the first few weeks, there is an increased risk of infections which may be superficial or deep. There may be complications of joint dislocation or blood clots in the blood vessels. Blood thinners are usually prescribed after the surgery to prevent blood clots. In the long term, there may be persistent pain, weakness, dislocation or loosening of the implant.

Outcome

Total knee and hip replacements are one of the most successful surgeries in modern medicine. Joint replacement surgery usually lasts for many years. With advances in materials, implants, and techniques the lifespan of the surgery is further proposed to increase. 

Cementless and cemented total knee replacements are both successful surgeries depending upon the needs of the patient. Adequate patient selection through physical examination and imaging is important before opting for cemented or cementless total knee replacement.

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Based on 93 reviews
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.