The Journal of Arthroplasty Vol. 24 No.

6 2009

Preliminary Results of an Uncemented Trabecular

Metal Tibial Component in Total Knee Arthroplasty

Anthony T. Helm, FRCS (Tr+ Orth), Cronan Kerin, MRCS,

Simon R.A. Ghalayini, MRCS, and George J. McLauchlan, FRCS (Tr+Orth)

Abstract: Trabecular metal has several theoretical advantages for the long-term
survival of a tibial component. We report the results of a prospective cohort of 105
consecutive primary total knee arthroplasties using an uncemented trabecular metal
(tantalum) tibial component at a minimum 3-year follow-up (range, 36-56 months).
There was a significant improvement in Oxford Knee scores and Short Form-12
scores postoperatively. There was no radiolucency at the implant-bone interface on
any postoperative radiograph. There has been one (1%) revision of the tibial
component for trauma. The 3-year results using this prosthesis are as good as those
published for the commonly used cemented prostheses. Longer follow-up is required
to see whether these results are maintained over time. Keywords: total knee
arthroplasty, uncemented, trabecular metal.
© 2009 Elsevier Inc. All rights reserved.

The NexGen Legacy total knee arthroplasty (Zim-
mer, Warsaw, IN) was introduced in 1996. It was
an evolution of the Miller-Galante II system. In the
Australian and Swedish Arthroplasty Registers, it is
one of the best performing knee prostheses, with a
low rate of revision [1,2]. The trabecular metal
tibial component (TMT) was introduced to the UK
in 2002. It is a monoblock design consisting of a
trabecular metal tray with 2 hexagonal pegs for
initial fixation and an articular surface of ultrahigh-
molecular-weight polyethylene (Fig 1). The articu-
lating surfaces and the polyethylene were
unchanged from the cemented version of the
NexGen. Trabecular metal implants are made
from elemental tantalum and consist of intercon-
necting pores resulting in a biomaterial that is 80%
From the Department of Orthopaedic Surgery, Lancashire Teaching
Hospitals NHS Trust, Sharoe Green Lane, Preston, UK.
Submitted October 29, 2007; accepted June 17, 2008.
No benefits or funds were received in support of the study.
Reprint requests: Department of Orthopaedic Surgery, Lanca-
shire Teaching Hospitals NHS Trust, Sharoe Green Lane, PR2 9HT
Preston, UK.
© 2009 Elsevier Inc. All rights reserved.
0883-5403/08/2406-0017$36.00/0
doi:10.1016/j.arth.2008.06.018
porous and has a modulus of elasticity equivalent to
that of bone. The porosity of the structure allows
for bone ingrowth, and the modulus of elasticity
allows for physiologic transfer of stresses from
implant to bone [3,4], which will theoretically
stress shield the proximal tibia to a lesser degree
and should therefore result in no loss of fixation in
the area of bone ingrowth.
Previous work has shown good clinical results
with this trabecular metal tibial prosthesis at 2 years'
follow-up [3]. In the UK, new joint arthroplasties
must show evidence that they are likely to have a
revision rate of less than 10% at 10 years. Three-
year data are the earliest point at which this can be
estimated. We report the results of a cohort of 105
consecutive primary total knee arthroplasties
(TKAs) in 103 patients using an uncemented TMT
component at a minimum 3-year follow-up.
Materials and Methods
We prospectively collected data on 103 unse-
lected patients (105 knees) undergoing TKA using
the NexGen prosthesis with a TMT component.
Over this time, the only reason a TMT knee was not

941
942 The Journal of Arthroplasty Vol. 24 No. 6 September 2009
Fig. 1. Photograph of the TMT.
implanted was the unavailability of kit or significant
anatomical deformity. All the patients were con-
sented for the procedure and had standard data
recorded preoperatively including age, sex, body
mass index, diagnosis, Oxford Knee Score (OKS),
and Short Form-12 (SF-12) Score. All procedures
were performed either by the senior author (GJM)
or under the senior author's supervision. The
procedure was performed through a midline ante-
rior incision and medial parapatellar approach. The
posterior cruciate ligament was retained and
patellar resurfacing was not routine. Postoperative
thromboembolic prophylaxis consisted of mechan-
ical prophylaxis with foot pumps and no routine
chemical prophylaxis except in the case of high-risk
patients, who were warfarinized for 3 months. Two
patients had staged bilateral procedures, making a
total of 105 knees in the original series. At a
minimum of 3-years' follow-up, 13 patients had
died and 3 patients were uncontactable, leaving 89
knees for analysis. Of these remaining knees, 79
(89%) were seen in a knee research clinic by the
first author (ATH). In this clinic, they had ante-
roposterior and lateral radiographs (non–weight
bearing) taken as well as repeating the OKS and
SF-12 scores and calculating the International Knee
Society (IKS) Clinical and Function scores. The
remaining 10 (11%) patients who could not attend
clinic were contacted by telephone to record their
OKS, IKS Function score, and SF-12 score.
Table 1. Preoperative and Postoperative Knee and SF-12 Scores
Oxford Knee SF-12 Physical
Score (n = 89) Component (n = 89)
Preoperative median (IQR) 46 (40-49) 25.93 (22.80-30.61)
Follow-up median (IQR) 20 (16-29) 39.42 (30.23-49.00)
P value b.0001 b.0001
IQR indicates interquartile range.
Results
The mean follow-up was 44 (36-56) months.
The mean age of patients in the series was 70 (43-
91) years and 62% were female. The mean body
mass index for the series was 30 (21-40) kg/m2.
The preoperative diagnosis for 85 (96%) of the
knees available for assessment was osteoarthritis.
Of the remaining 4 knees, 2 had rheumatoid
arthritis, 1 had a seronegative arthritis, and 1 had
posttraumatic arthritis.
Of the evaluated knees, 1 (1%) had the patella
resurfaced at the index procedure and 3 (3%) have
had a subsequent patellar resurfacing for persistent
anterior knee pain. There has been one revision of a
TMT in our series. This was in a 73-year-old male
patient who was initially performing very well with
his primary TKA, but was unfortunate enough to
sustain a fall 2 months after the index procedure.
After this fall, he complained of persistent pain
around the tibial component despite satisfactory
appearances of plain x-rays, 2 bone scans, and a
computed tomography scan of the knee. Blood
marker results were also normal. A second opinion
regarding treatment was sought from a senior
member of the consultant orthopedic team who
performed a revision procedure 27 months after the
index procedure. At surgery, the tibial component
was clearly well fixed and had to be removed by
introducing a fine oscillating saw through the
implant-bone interface and sawing through the 2
fixation pegs. The total knee was revised to a
stemmed revision implant. Despite the revision
procedure, this patient continued to complain of pain.
Shapiro-Wilk's W Test for normality revealed that
the postoperative knee and SF-12 scores were not
normally distributed, and hence median and inter-
quartile ranges are quoted. Table 1 shows the
preoperative and postoperative OKS and SF-12 scores
as well as the postoperative IKS scores. To compare
preoperative and postoperative OKS and SF-12
physical scores, the Wilcoxon matched-pairs signed-
rank test for nonparametric data was used. This
showed a significant improvement (P N .0001) for
both scores. Fig. 2 shows a plot of survival function
IKS Clinical Score Pain Component of IKS IKS Functional
(n = 79) Clinical Score (n = 10) Score (n = 89)
– – –
94 (90-96) 45 (45-50) 90 (73-100)
– – –

Fig. 2. Cumulative survival of the TMT component.
(cumulative proportion surviving) of the observed
data using life-table analysis of censored and uncen-
sored observations, with whiskers representing the
standard error of the relevant time interval. There
were no radiolucent lines under the tibial component
on any postoperative radiograph (Fig. 3).
There has been one early infection and one late
(2 years) hematogenous infection. Both of these
have been treated with debridement and retention
of all of the components with eradication of the
infection as indicated by hematological, biochem-
ical, and microbiological markers. There have been
4 (4%) venographically confirmed deep venous
thromboses (2 popliteal and 2 below knee) and 1
(1%) nonfatal pulmonary embolism.
Discussion
The TKA prostheses most frequently used in
today's practice have cemented components [1,2].
These have shown excellent clinical results in the
long-term [5-7]. It is well known that cement is able
to provide good initial fixation and, with pressuriza-
tion into cancellous bone, can prevent polyethylene
debris from entering the interface between implant
and bone. The fixation can, however, weaken with
time, and cement debris within the articulation can
lead to accelerated wear. Cementless implants are less
commonly used, but of the prostheses available, some
have also shown good long-term clinical results [8-
10]. The potential advantages of cementless implants
are retention of bone stock, less chance of third-body
wear due to the absence of cement, shorter operative
time, and easier treatment of periprosthetic fractures.
Although there are a variety of methods of
achieving satisfactory initial fixation in cementless
components, none are as consistent as using
Trabecular Metal Knee Arthroplasty  Helm et al 943
cement. The TMT component has 2 hexagonal
pegs, which are impacted into corresponding
cylindrical drill holes in the cancellous bone of the
cut surface of the tibia. Owing to the extremely high
coefficient of friction of trabecular metal, a secure
initial interference fit is made.
Trabecular metal is a porous elemental tantalum
biomaterial, which has a cellular structure resem-
bling the bone and approximates the physical and
mechanical properties of the bone more closely
than other prosthetic materials. The modulus of
elasticity is equivalent to that of bone and, there-
fore, allows for physiologic transfer of mechanical
stresses to the bone; that is, there should not be a
great deal of difference, if any, in the deflection of
the prosthesis compared to the deflection of the
proximal tibial metaphyseal bone on cyclical weight
bearing. With a tibial baseplate made from trabe-
cular metal, this should result in less stress shielding
in the proximal tibia which would otherwise
weaken this portion of the bone [3]. Later bony
ingrowth in traditional uncemented implants gen-
erally amounts to around only 30% to 40% of the
surface area. The 80% porous structure of trabe-
cular metal allows for bone ingrowth in more than
90% of the available surface [4].
There has been a recent trend toward TKA in
younger patients [1]. The potential advantages of
cementless fixation with this component such as
strong initial fixation, conservation of bone stock,
predictable bony ingrowth, and reduction in stress
shielding could be of particular value in the
younger subset of patients.
There has been one early acute deep infection
and one late hematogenous deep infection in the
series. The late infection occurred in a patient with
rheumatoid arthritis. Both of these infections were
treated with debridement and retention of all of the
Fig. 3. Postoperative anteroposterior radiograph of the
TMT component.
944 The Journal of Arthroplasty Vol. 24 No. 6 September 2009
components, and both have recovered according to
clinical examination, laboratory testing of erythro-
cyte sedimentation rate, and C-reactive protein and
microbiological examination of synovial fluid aspi-
rated from the joints. It could be postulated that
because of the extensive bony ingrowth seen with
trabecular metal components, the component
actually acquires a blood supply and therefore
antibiotic penetration into the interface could be
better than with a traditional uncemented or
cemented component.
In conclusion, the TMT used in this series has
shown no evidence of loosening at a minimum of 3
years' follow-up and the prosthesis as a whole has
performed very well clinically. Its early results are
comparable to those prostheses most commonly
used as reported by the arthroplasty registers. The
longer term results from this prosthesis are awaited
with interest.
Acknowledgments
The authors would like to thank Mr Irfan
Siddique, MRCS, for his help with the statistical
analysis of the results.
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