Accepted Manuscript

Results of Cemented versus Cementless Primary Total Knee Arthroplasty Using the
Same Implant Design

Adam J. Miller, BS, Jeffrey Stimac, MD, Langan S. Smith, BS, Anthony Feher, MD,
Madhusudhan Yakkanti, MD, Arthur L. Malkani, MD

PII: S0883-5403(17)31053-7
DOI: 10.1016/j.arth.2017.11.048
Reference: YARTH 56255

To appear in: The Journal of Arthroplasty

Received Date: 19 September 2017

Revised Date: 13 November 2017
Accepted Date: 17 November 2017

Please cite this article as: Miller AJ, Stimac J, Smith LS, Feher A, Yakkanti M, Malkani AL, Results of
Cemented versus Cementless Primary Total Knee Arthroplasty Using the Same Implant Design, The
Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.11.048.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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 ACCEPTED MANUSCRIPT

Results of Cemented versus Cementless Primary Total Knee Arthroplasty

Using the Same Implant Design

Adam J. Miller, BS
University of Louisville School of Medicine

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500 S Preston Street
Louisville, KY 40204, USA
440-382-9521 phone
adam.miller.1@louisville.edu

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Jeffrey Stimac, MD
KentuckyOne Health Medical Group

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201 Abraham Flexner Way, Suite 100
Louisville, KY 40202, USA
jeffreystimac@gmail.com

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Langan S. Smith, BS
KentuckyOne Health Medical Group
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201 Abraham Flexner Way, Suite 100
Louisville, KY 40202, USA
LanganSSmith@KentuckyOneHealth.org
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Anthony Feher, MD
Franciscan Health Total Joint Reconstruction
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12188-B North Meridian St.

Suite 250
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Carmel, IN 46032, USA

Afeher3698@gmail.com

Madhusudhan Yakkanti, MD
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Louisville Orthopaedic Clinic

4130 Dutchman's Lane
Louisville, KY 40207, USA
madhuyakkanti@gmail.com
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Arthur L. Malkani, MD (Corresponding Author)

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University of Louisville Adult Reconstruction Program

550 S. Jackson Street, 1st floor, ACB
Louisville, KY 40202, USA
502-852-6902 phone
502-587-0860 fax
arthur.malkani@louisville.edu
 ACCEPTED MANUSCRIPT

Results of Cemented versus Cementless Primary Total Knee Arthroplasty Using the Same
Implant Design

ABSTRACT

BACKROUND: Although cemented total knee arthroplasty (TKA) continues to be the gold

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standard, there are patient populations with higher failure rates with cemented TKAs such as the
obese, morbidly obese, and younger active males. Cementless TKA usage continues to increase
due to the potential benefits of long term biologic fixation similar to the rise in cementless THA.

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The purpose of this study was to evaluate the clinical and radiographic results of cementless
TKA using a novel highly porous cementless tibial baseplate.

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METHODS: This was a retrospective matched case control of 400 primary TKAs comparing
cementless versus cemented TKAs using the same implant design (Stryker Triathlon, Stryker
Inc., Mahwah, NJ). 200 patients with a mean age of 64 years (range: 42 to 88 yrs) and BMI of
33.9 (range: 19.7 to 57.1) were matched to 200 primary cemented TKA patients with a mean age

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of 64 (range: 43 to 87 yrs) and BMI of 33.1 (range 22.2 to 53.2). The mean follow up in the
cementless group was 2.4 years (range 2 to 3.5 yrs) and the cemented group 5.3 yrs (range 2 to
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10.9 yrs). Clinical and radiographic analyses were evaluated. Statistical analysis was performed
using Microsoft Excel Version 15.21.1.

RESULTS: There was no statistical difference in age, BMI, and pre-op KSS scores between the
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two groups (p=0.22; p= 0.82; p=0.43). Patients in both groups had a similar incidence of
postoperative complications (p =0.90). Cementless group had 7 revisions with one aseptic
loosening of the tibial component (0.5%). Cementless tibial baseplates demonstrated areas of
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increased bone density at the pegs of the tibial baseplate. The cemented group had 8 total
revisions with 5 cases of aseptic loosening (2.5%).
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CONCLUSIONS: Early results of cementless TKA using a highly porous tibial baseplate
designed with a keel and four pegs appear promising with one case of aseptic loosening at
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minimum two year follow up. As the demographics of patients undergoing TKA change to
include younger, obese, and more active patients, along with increased life expectancy, the use of
a highly porous cementless tibial baseplate maybe be beneficial in providing long term durable
biologic fixation similar to the success of cementless THA.
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KEYWORDS: Primary TKA; cementless; cemented; outcomes

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1 INTRODUCTION

2 Cemented TKA continues to be the gold standard for primary TKA. However, patient

3 demographics are changing to include younger, obese, and more active patients [1-3]. Cemented

4 TKAs have demonstrated higher failure rates in certain groups such as obese and younger

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5 patients [4-6]. This poses a challenge to orthopedic surgeons as the largest growth rate for

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6 prospective TKAs is occurring in the <65 year old patient population. The <65 group is

7 expected to represent the majority (>50%) of the anticipated primary TKA burden between 2010

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8 to 2030 [1]. Life expectancy has also increased creating further need for implants to provide

9 more durable long term fixation similar to the success of cementless total hip arthroplasty [6-8].

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The past results of cementless TKA have not been favorable due to multiple reasons
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11 including patch porous coating, poor tibial locking mechanisms, and use of first generation

12 polyethylene leading to osteolysis with migration of particles through screw holes [9, 10]. These
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13 earlier cementless TKA design iterations were unsuccessful and suffered from a variety of
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14 setbacks. Many of these earlier cementless designs did not offer adequate mechanical fixation
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15 for immediate implant stability irrespective of the complications leading to osteolysis [11]. With

16 an understanding of these failure mechanisms and advances in biomaterials, most of the earlier
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17 design flaws have been corrected leading to improved survivorship of cementless TKA implants

18 (Table 1). Given the success of cementless THA and the increased demands placed on current
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19 cemented TKA designs due to younger and more active patients and greater life expectancy, the
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20 use of cementless TKA needs to be further evaluated. The purpose of this study was to compare

21 the results of cementless TKA using a novel highly porous tibial baseplate with a keel and 4 pegs

22 to a cemented TKA using the same kinematically designed total knee implant.

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24 METHODS AND MATERIALS

25 This was a retrospective matched case control study performed at the same institution

26 with IRB approval. 200 cementless TKAs (Stryker Triathlon, Stryker Inc., Mahwah, NJ)

27 performed between June 2013 and September 2014 using a highly porous tibial baseplate with a

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28 keel and 4 pegs were reviewed. These were compared to a matched cohort using a cemented

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29 TKA with the same kinematic design (Stryker Triathlon, Stryker Inc., Mahwah, NJ) from a

30 prospective total joint registry. The cementless group consisted of 125 females and 74 males

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31 with an average age of 64 years (42 to 88 yrs), average BMI 33.9 (19.7 to 57), and a mean follow

32 up of 2.4yrs (2 to 3.5 yrs). The matched cohort consisted of 200 cemented TKAs with 125

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females and 74 males with an average age of 64 years (47 to 87 yrs), average BMI 33 (range 22
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34 to 53) with a mean follow up of 5.3 yrs (2 to 10.9 yrs).

35 All primary cementless knee arthroplasties were performed using a parapatellar or

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36 subvastus approach and a posterior stabilized Stryker Triathlon Tritanium™ tibial baseplate
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37 along with a cementless peri-apatite coated femoral component, a cementless patella component
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38 and cross-linked polyethylene liner (Fig 1.). The cemented group consisted of a posterior

39 stabilized or cruciate retaining Stryker Triathlon™ total knee with a cemented all polyethylene
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40 patella component. The cementless, screwless, tibial baseplate was developed from pure

41 titanium powder using additive manufacturing technology which can optimize porosity for
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42 ingrowth and provide solid material for strength in addition to manufacturing complex
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43 geometries. Mechanical testing of this cementless tibial baseplate demonstrated excellent

44 resistance to lift off [42].

45 The cementless group received a peri-apatite coated cementless femoral component in all

46 cases, along with a cementless patellar component. All components implanted in the cohort were

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47 cemented including the use of an all polyethylene cemented patella component. Most of the

48 cemented total knees were performed prior to the introduction of the highly porous tibial

49 baseplate. The selection criteria for cementless TKA was based on the bone quality. Patients

50 with adequate bone quality at the periphery or rim of the tibial metaphysis were selected for

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51 cementless fixation. The selection process was consistent and performed by the same surgeon.

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52 The same anesthesia and postoperative care protocol were used in both groups including regional

53 anesthesia with a combined femoral and sciatic nerve block along with IV sedation or general

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54 anesthesia. In each case, a pneumatic tourniquet was used and postoperative drains were placed

55 prior to closure. The same postoperative physical therapy protocol was also used in both groups

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which consisted of immediate weight bearing with passive and active motion exercises. All
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57 patients received the same pre-operative antibiotic and postoperative VTE prophylaxis protocol.

58 Both cohorts were analyzed for primary outcome measures along with pre and
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59 postoperative range of motion, pre- and postoperative Knee Society Scores (KSS), and medical
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60 or surgical complications. Radiographs were obtained at follow up visits to evaluate signs of

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61 progressive radiolucent lines, osteolysis, component loosening, malalignment, and subsidence

62 (Figure 2). Analysis of the study group and the matched cohort was performed using Microsoft
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63 Excel version 15.21.1. Two-tailed independent t test was used for continuous variables with

64 normal distribution. Chi Square analysis was used to compare categorical variables. Statistical
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65 significance was defined as p < 0.05.

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66

67 RESULTS:

68 400 primary total knee procedures were reviewed in this study consisting of 200

69 cementless TKAs matched to 200 cemented TKAs with the same kinematically designed Stryker

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70 Triathlon total knee implant. There were no statistical differences in age, body mass index, and

71 pre-operative KSS between the two matched cohorts (p=0.22; p= 0.82; p=0.43, Table 1). The

72 cementless group had a slight improved 2 year KSS functional scores compared to cemented (76

73 ± 20.4 for cementless and 70.2 ± 22.3 for cemented, p=0.016). KSS knee scores were also

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74 somewhat improved in the cementless group compared to the cemented group (94.1 ± 6.2 in

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75 cementless and 91.5 ± 9.8 in cemented (p=0.007, Table 3).

76 Each group had similar improvements in Knee Society Scores, 53.8 ± 13.8 (Range: 9 to

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77 80) in the cementless group and 52.4 ± 16.7 (range: 0 to 81) in the cemented group (p=0.47).

Cemented and cementless groups had similar postoperative knee extension of 0.23 ± 1.7 degrees

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and 0.11 ± 0.9 respectively (p=0.385). The cementless group demonstrated slight improvement
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80 in postoperative knee flexion compared to the cemented cohort, 119.4 ± 7.0 vs. 116.4 ± 7.8
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81 (p=0.003).

82 Both groups had similar rates of failure leading to revision (8 cemented vs. 7 cementless,
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83 p=0.069). There was one case of aseptic tibial component loosening in the cementless group
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84 (0.5%) whereas there were 5 cases of aseptic loosening in the cemented cohort (2.5%). Though

85 there were more cases of aseptic loosening in the cemented group, this comparison was not
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86 significant, p=0.2 (Table 4). The cementless group had 7 total revisions; one revision for flexion
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87 instability treated with liner exchange, one extensor mechanism rupture treated with liner
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88 exchange and quad repair, one postoperative infection treated with liner exchange and I&D, one

89 recurrent patellar dislocation with liner exchange and quad tendon repair, and one case where the

90 patella was not resurfaced during the index procedure which subsequently developed

91 patellofemoral arthrosis requiring patella arthroplasty. Except for the one aseptic tibial

92 component loosening in the cementless group, all other cementless cases demonstrated

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93 radiographic dense spot welding or increased bone density primarily around the four tibial pegs.

94 There were no cases of aseptic loosening in either the cementless femoral or patella components.

95 The cemented group had 8 total revisions, including five cases of aseptic loosening; one

96 patellar loosening, two tibial component loosening, and two both femoral and tibial component

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97 failures. There were two revisions due to flexion instability treated with conversion to a posterior

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98 stabilized design, and one case of liner exchange with irrigation and debridement performed for a

99 traumatic arthrotomy after a postoperative fall. There were no postoperative infections in the

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100 cemented group and one infection in the cementless group. Each group had a similar incidence

101 of medical and surgical postoperative complications.

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103 DISCUSSION:

104 Total knee arthroplasty is the treatment of choice for end stage osteoarthritic knee disease
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105 when all non-operative methods have failed. The results of cemented Stryker Triathlon TKA
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106 have demonstrated excellent results in a prior study [12]. However, as the patient population
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107 receiving TKA continues to evolve to include obese, younger and more active patients who are

108 also living longer, surgeons are faced with the challenge of providing durable long term implant
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109 fixation. Gioe et al. in a study from 1991 to 2002 on 5760 primary TKA’s attributed 40% of

110 their revisions due to aseptic loosening [13]. Younger patients with active lifestyles and obese
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111 patients pose a challenge to the gold standard of cemented TKA due to concerns of aseptic
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112 loosening [8]. Aseptic loosening is one of most common etiology of failure with cemented TKA

113 designs faced by younger and heavier patients [14-16]. Abdel et al. in a review of cemented

114 TKA’s demonstrated increased failure due to aseptic loosening in obese patients despite well

115 aligned knees [4]. Bagsby et al. demonstrated higher failure rates with cemented primary TKA

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116 compared to cementless TKA in the morbidly obese, 89% survivorship versus 99% respectively

117 [17]. Higher failures rates have also been demonstrated in younger patients undergoing primary

118 TKA [18]. Gioe et al. showed cemented TKA survival rate at 85% in a cohort (n = 1047) of

119 patients less than 55 years old over a 14 year period [18]. Meehan et al. demonstrated that the

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120 risk of revision surgery due to aseptic loosening in cemented primary TKA at one year

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121 postoperatively in patients <50 years old was 4.7x greater than that of a >65 year old cohort [16].

122 A Kaplan-Meier survivorship analysis from McCalden 2013 showed primary cemented TKA

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123 patients under age 55 with significantly higher rates of revision due to aseptic loosening at both 5

124 and 10 years post operatively compared to cementless TKA.

125
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Given the success of cementless THA, there has been an increased interest in the use of
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126 cementless TKA to provide to same benefits of biologic fixation over mechanical cement

127 fixation for long term durability. Initial cementless TKA implants however suffered from design
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128 flaws including poor patch porous coatings, poor tibial locking mechanisms and use of first
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129 generation polyethylene that led to increased wear and osteolysis with poor outcomes [8, 10, 19].
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130 Ritter et al. looked at 73 cementless knees from 1984 to 1986 and demonstrated that many of the

131 early cases of cementless TKA failures were due to the metal backed patella [20]. 12 of the 15
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132 failures leading to revision in their series were due to patellar component failure with an overall

133 76.4% survivorship at 20 years. The survivorship of the cementless femoral component was
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134 96.8%. Cementless femoral components have demonstrated excellent survivorship over the long
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135 term in many series [4, 21, 22]. Many of the early cementless patella component failures

136 discouraged orthopedic surgeons away from the use of cementless TKA implants. These early

137 patellar design failures have been addressed through numerous improvements including the use

138 of thicker, current generation polyethylene, reduction in sharp metal boarders and a higher

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139 degree of conformity which have led to highly favorable outcomes without the osteolysis and

140 accelerated wear noted in first generation designs.[23-26].

141 Another area of early design failure of cementless TKA was noted in the higher failure

142 rates of cementless tibial baseplates. Initial cementless tibial baseplate designs demonstrated

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143 increased incidence of progressive radiolucent lines at the implant/bone interface leading to

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144 aseptic loosening and subsequent component failure [27, 28]. In all likelihood, initial design

145 cementless tibial baseplates did not provide adequate immediate implant stability critical for

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146 successful biologic ingrowth [29]. Dunbar et al. using radiosterometric analysis (RSA)

147 demonstrated that immediate rigid implant stability is essential for successful long term

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biological fixation in a study of cementless TKA [30].
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149 Despite the initial setbacks in early cementless tibial component designs, these design

150 flaws have mostly been addressed leading to a reevaluation of cementless TKA. Harwin et al. in
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151 a review of a cementless modern design TKA with peri-apatite coating to improve the potential
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152 of biologic fixation along with screw fixation on the tibial baseplate to provide immediate rigid
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153 fixation demonstrated 99% survivorship at an average of 4 years follow up [19]. Beaupre et al.

154 in a randomized control trial evaluated a modern design cementless tibial component coated with
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155 hydroxyapatite versus a cemented tibial baseplate with the same design at 5 years and

156 demonstrated equivalent outcomes [31]. Cross et al. reviewed a cohort of 1000 patients who
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157 received a hydroxyapatite coated cementless TKA implants with a survivorship of 99% at 10
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158 years with aseptic loosening as the endpoint [32]. Bagsby et al. demonstrated 99% survivorship

159 at 3.6 years with cementless TKA compared to 89% survivorship with cemented TKA in the

160 morbidly obese patient [17]. Several other studies have demonstrated improved survivorship of

161 cementless TKA compared to the results of earlier cementless designs [33, 34].

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162 Due to the challenge of obtaining rigid fixation in early cementless design, adjunctive

163 fixation mechanisms were utilized in earlier designs [3]. Screws were used in tibial baseplates to

164 help insure initial stability of the implant to increase the probability of adequate biological

165 fixation [36]. However tibial screws served as a conduit for osteolysis via formation channels

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166 for debris [3, 11]. Holloway et al. showed reliable fixation with screwless cementless tibial

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167 baseplates at an average of 7.6 years follow up [37]. Other studies have also demonstrated no

168 advantage to using tibial baseplate with screws versus no screws [38, 39].

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169 With advances in technology, new implants have been developed using highly porous

170 components which have obviated the need for adjunct tibial baseplate screw fixation to provide

171
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immediate implant stability [9, 40, 41]. The cementless tibial baseplate used in this study was
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172 developed using additive manufacturing 3D printed technology with a keel and four pegs

173 designed to provide immediate implant stability [42]. Nam et al. in a similar study comparing
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174 cementless versus cemented total knee implants demonstrated no difference in blood loss and
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175 change in hemoglobin but did show decreased operative time in the cementless group. [41].
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176 In our study, at an average follow up of 2.4 years following TKA using a cementless

177 highly porous tibial baseplate, we demonstrated a failure rate due to aseptic loosening of 0.5%.
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178 The matched cemented cohort used in this study with the same implant design had an aseptic

179 failure rate of 2.5%, p= 0.09. Given the history of cementless THA, once biological fixation is
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180 achieved with cementless TKA, in all probability it should remain durable over the long term.
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181 Radiographic analysis of the cementless tibial baseplate used in this study demonstrated

182 areas of dense bone ingrowth or spot welds primarily at the pegs similar to the areas of bone

183 density noted at the screws sites with cementless THA [43]. It is difficult to quantify the amount

184 or extent of biological fixation in cementless implants with plain radiographs. Future studies

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185 using micro CT or extreme CT scans would help quantify the exact location and extent of

186 ingrowth in these highly porous implants [44]. Some of the strengths of this study include the use

187 of the same kinematically designed TKA implant at the same institution along with the same

188 anesthesia and postoperative therapy protocol with the cemented cohort matched from the same

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189 prospective database.

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190 Given the higher failure rates of cemented TKA in younger, active, and obese patients

191 along with increased life expectancy, there has been an impetus towards the use of cementless

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192 TKA with the potential of long term durable biological fixation similar to the history and

193 evolution of cementless THA use in North America. The results of our study using a highly

194
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porous tibial baseplate with a keel and four pegs designed for immediately implant stability
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195 demonstrated excellent short term results and a failure incidence due to aseptic loosening

196 equivalent or somewhat better compared to a kinematically designed similar cemented implant.
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197 Many of the early design flaws of cementless TKA leading to increased wear, osteolysis and
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198 loosening have been addressed especially with current generation polyethylene and improved
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199 fixation methods using highly porous implants. Based on our study, young active patients and

200 obese patients who place greater demands and stress at the bone implant interface may benefit
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201 from the use of cementless TKA to obtain the benefits of durable long term biologic fixation.

202 Although the early results of this study of cementless TKA is encouraging, additional data is
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203 required to determine if the benefits of biologic fixation using a highly porous, current design
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204 cementless TKA can be realized over the long term similar to the history and success of

205 cementless THA.

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Arthroplasty, 2010. 25(1): p. 46-51.

38. Ferguson, R.P., M.G. Friederichs, and A.A. Hofmann, Comparison of screw and
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screwless fixation in cementless total knee arthroplasty. Orthopedics, 2008. 31(2): p. 127.
39. Schepers, A., L. Cullingworth, and D.R. van der Jagt, A prospective randomized clinical
trial comparing tibial baseplate fixation with or without screws in total knee arthroplasty:
a radiographic evaluation. J Arthroplasty, 2012. 27(3): p. 454-60.
40. Fricka, K.B., S. Sritulanondha, and C.J. McAsey, To Cement or Not? Two-Year Results
of a Prospective, Randomized Study Comparing Cemented Vs. Cementless Total Knee
Arthroplasty (TKA). J Arthroplasty, 2015. 30(9 Suppl): p. 55-8.

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41. Nam, D., et al., Perioperative and Early Postoperative Comparison of a Modern
Cemented and Cementless Total Knee Arthroplasty of the Same Design. J Arthroplasty,
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42. Bhimji, S. and R.M. Meneghini, Micromotion of cementless tibial baseplates: keels with
adjuvant pegs offer more stability than pegs alone. J Arthroplasty, 2014. 29(7): p. 1503-6.
43. Schmalzried, T.P. and W.H. Harris, The Harris-Galante porous-coated acetabular
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Figure Legend

Figure 1: Picture of a cementless, highly porous tibial baseplate

Figure 2a: A/P, lateral and merchant radiographs of a 67-year-old patient with severe OA of the right
knee.

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Figure 2b: A/P, lateral and merchant radiographs one year postoperative right TKA using highly porous
cementless tibial baseplate, HA-coated cementless femoral component and cementless patella component.

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Figure 2c: A/P and lateral radiographs four years following index procedure with a well-functioning and
stable implant and no evidence of radiolucent lines.

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Table 1: Cementless TKA Survivorship Studies

Research Group Length of Follow-up Survivorship Design

Harwin (2015) 4 years 99.50% Triathlon
Kwong (2014) 7 years 95.70% Nex Gen
Schroder (2001) 10 years 97.10% AGC-2000

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Khaw (2002) 10 years 95.60% PFC
Hofmann (2002) 10 years 99.00% Natural
Wantabe (2004) 13 years 96.70% Osteonics

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Cross (2005) 10 years 99.60% HA
Hardeman (2007) 10 years 97.10% Profix
Tai (2006) 12 years 97.50% HA

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Wantabe (2004) 13 years 96.70% Osteonics
Goldber (2004) 14 years 99.00% MG-I
Kim (2014) 17 years 98.90% Nexgen

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Tarkin (2005) 17 years 97.90% LCS-RP
Whiteside (2002) 18 years 98.60% Ortholoc-I
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Buechel (2002) 20 years 97.70% LCS-RP
Ritter (2009) 20 years 96.80% AGC
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Table 2:
Patient demographics and outcome variables comparing matched Cementless and Cemented
cohorts in total knee arthroplasty.

Cementless Cemented
Demographic p value
(n=200) (n=200)
Age (Years) 64.3 ± 8.3 64.4 ± 8.2 0.82

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Gender 1
• Male 74 (37.0%) 74 (37.0%)
• Female 126 (63.0%) 126 (63.0%)
Side 0.904

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• Left 103 (51.5%) 68 (49.2%)
• Right 96 (48.0%) 70 (51.8%)
BMI 33.9 ± 7.5 33.1 ± 6.5 0.22

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Follow-up Time
27.6 ± 3.5 63.4 ± 23.0 <0.00001
(Mo)

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Table 3:
Comparison of outcome scores in matched Cementless versus Cemented Total Knee
Arthroplasty.

Cementless Cemented
Outcome Score p-value
TKA TKA
KSS Function Score 76.0 ± 20.4 70.2 ± 22.3 0.016

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Change in Function
35.6 (± 19.8) 26.04 ± 26.6 0.0014
Score
KSS Knee Score 94.1 ± 6.1 91.6 ± 9.8 0.0076

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Change in Knee Score
53.8 ± 13.8 13 52.4 ± 16.7 0.385

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Table 4:
Total Revision stratification comparison in matched Cementless versus Cemented Total Knee
Arthroplasty.

# of revisions # of revisions
Reason for revision - cementless - cemented p-value

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TKA TKA
Aseptic Loosening 1 (0.5%) 5 (2.5%) 0.212
Infection 1 (0.5%) 0 (0.0%) 0.316

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Extensor Mechanism
1 (0.5%) 0 (0.0%) 0.316
Rupture
Flexion Instability 1 (0.5%) 2 (1.0%) 0.562

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Global Instability 1 (0.5%) 0 (0.0%) 0.316
Patellar Dislocation 1 (0.5%) 0 (0.0%) 0.316
Patellofemoral Arthrosis 1 (0.5%) 0 (0.0%) 0.316
0.316

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Open Arthrotomy 0 (0.0%) 1 (0.5%)
Total # of revisions 7 (3.5%) 8 (4.0%) 0.069
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Figure 1: Picture of a cementless, highly porous tibial baseplate

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Figure 2a:

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Figure 2c:

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Figure 2a: A/P, lateral and merchant radiographs of a 67-year-old patient with severe OA of the
right knee.
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Figure 2b: A/P, lateral and merchant radiographs one year postoperative right TKA using highly
porous cementless tibial baseplate, HA-coated cementless femoral component and cementless
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patella component.
Figure 2c: A/P and lateral radiographs four years following index procedure with a well-
functioning and stable implant and no evidence of radiolucent lines.
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