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. 2025 Sep 13;70:103188. doi: 10.1016/j.jcot.2025.103188

Cementless total knee arthroplasty in post-traumatic or Post-ACL knees: A case series

Maha L Khan a, Sara Winfrey b, Nicholas M Brown b,⁎
PMCID: PMC12475513  PMID: 41020056

Abstract

Background

Advancements in prosthetic technology have allowed for the reemergence of cementless fixation particularly in younger or obese patients [1–4]. While previous research on cementless fixation in varied populations is promising, there are few studies, to our knowledge, investigating outcomes in patients with post-traumatic osteoarthritis. The objective of this case series was to analyze the clinical outcomes and reoperation rates of cementless total knee arthroplasty (TKA) for post-traumatic arthritis.

Methods

This study was an institutional review board (IRB) exempt retrospective review of cementless TKAs at an academic, tertiary referral center. Patients with a history of anterior cruciate ligament (ACL) reconstruction and/or knee trauma were included. Basic univariate statistics were used to analyze the data.

Results

Eight patients were included: three patients with a history of ACL reconstruction, two with a prior femoral fracture, one with a history of patellar fracture and open reduction and internal fixation of the tibial plateau, one with a tibial fracture, and one patient with a previous fracture of the tibia and femur. The mean age at surgery was 57.5 years. One patient was lost to follow-up. There were no acute complications, and mean follow-up time was 10.1 months in the remaining seven patients. At four months post-operative, one patient had an acute prosthetic infection after a spine infection that was effectively treated with irrigation & debridement (I&D) polyethylene exchange.

Conclusion

While the sample size and follow-up time is limited, use of cementless implants in TKA is safe in post-ACL or post-traumatic knees in the short-term and indicates the need for more research in this patient population.

Graphical abstract

Image 1

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1. Introduction

Cementless fixation in total knee arthroplasty (TKA) has re-emerged due to advancements in cementless prosthetic technology and new evidence supporting its use in younger and/or obese patients.1, 2, 3, 4 Given the increased risk of aseptic loosening and decreased implant survivorship in younger patients, cementless5 TKA is theoretically better for this patient population as it allows more dynamic integration between the bone and the implant.6 This allows for increased stress on the knee implant as bone can remodel whereas cement will only loosen over time. The American Joint Replacement Registry reports that over 20 % of total knee replacements today are cementless.7 Despite its growth over the last few years, cementless TKA is still not widely adopted due to concern for increased rates of loosening and osteolysis observed in previous cementless designs.2,8,9

A recent meta-analysis by Rainey et al. showed at least equivalent survivorship and patient reported outcomes across 27 randomized controlled trials comparing cemented vs. cementless TKA.10 Another meta-analysis by Chen et al. of eight RCTs showed similar outcomes including rate of survival, clinical scores, and mobility when comparing cemented versus cementless.11 However, their analysis also showed that while cementless implants had a lower incidence of radiolucent lines, cemented implants tended to migrate less.11 Furthermore, an age of greater than 65 years has historically been a contraindication for cementless TKA due to decreased bone quality. However, many recent studies have shown that cementless TKA continues to be performed in all age groups, and clinical outcomes and survivorship of cementless implants are not affected by age or history of osteoporosis.12, 13, 14

To our knowledge, there has been no analysis comparing clinical outcomes and differences in revision rates between cemented and cementless TKA for post-traumatic osteoarthritis (PTOA) including prior anterior cruciate ligament (ACL) repair. Increased research on outcomes of cementless TKA is especially important in this population as cementless TKA reduces operative time and procedure cost.15 Additionally, previous research on cementless TKA on patients younger than 50, who are more likely to require TKA due to previous injury and/or PTOA, has shown positive results at a mean follow-up time of four years.5 The aim of this case series was to investigate outcomes and reoperation rates of cementless total knee arthroplasty in post-traumatic and/or post-ACL reconstruction knees.

2. Methods

The present study was approved by the institutional review board (IRB) and deemed an exempt study due to its retrospective design, use of existing and anonymized patient data, and its minimal risk to patients. Therefore, the requirement for patient consent was waived. The surgeons’ logs were retrospectively reviewed for all surgeons doing cementless TKAs at an academic, tertiary referral center between 2020 and 2024. The inclusion criterion was an x-ray that revealed hardware from prior ACL reconstruction and/or knee trauma. Patient cases were included consecutively if they met this inclusion criteria. Descriptive statistics were used to analyze the collected data. Cruciate retaining (CR) implants were used in all TKAs. Additionally, Attune cementless implants were used in the majority of knees while the Djo Empower and the Stryker Triathlon systems were used in one TKA each. Titanium tibial trays were used in all knees. Clinical records were reviewed for length of stay, reoperation, revision, complications up until May 2025, and demographics. Radiographs were evaluated for signs of loosening, migration, or radiolucent lines.

3. Results

Eight cementless TKAs in post-traumatic or post-ACL reconstruction knees were identified in this review and analyzed for post-operative complications. Three patients had a history of ACL reconstruction, and five patients had a history of post-traumatic osteoarthritis from previous fractures. One patient had a closed fracture of the patella and a history of open reduction and internal fixation (ORIF) of the tibial plateau. Two patients had a history of ORIF of the femur. The surgical history of the fourth patient was unknown, but the medical history included fracture of the tibia and femur as well as a degloving injury to the anterior tibia from a motor vehicle collision. The last patient had a previous fracture of the tibia. The year of the previous surgery was only known for 4 patients, and the elapsed time between the previous surgery and TKA was 4, 11, 30, and 34 years (mean = 19.8 years). There were 4 males and 4 females included in the study with a mean BMI of 31.8 kg/m2 (range = 22.50–34.39). Six out of seven patients had a BMI greater than 30 kg/m2 indicating obesity (Table 1). The mean age at surgery was 57.5 years (range = 43–70). The mean length of hospital stay was 2.4 days. One patient was lost to follow-up after 3 weeks post-op. Of the remaining six patients, the mean follow-up time was 10.1 months, range 1 month–28 months. The mean range of motion (ROM) at the most recent follow-up for these patients was 123 (SD = 10) degrees.

Table 1.

Summary of cases.

Case Sex Age at time of Surgery BMI Knee History of Trauma Implant
Type		 Post-operative ROM Length of Follow-Up Complications
1 Female 70 32.5 R Fracture of tibial plateau Attune 0–130 28 months None
2 Male 61 30.6 L ACL Attune 0–125 4 months None
3 Female 43 34.4 R ACL Attune 0–130 12 months None
4 Male 57 35.9 L ACL Attune 5-120a 6 months None
5 Female 60 29.5 R Fracture of the distal femur Attune 5–120 1 month Resolved medial pain at 1-month post-op
6 Female 51 39.0 L Fractures of the tibia and femur Djo EMPOWR N/A Lost to follow up None
7 Male 68 30.4 R Fracture of the femur Stryker Triathlon 0–110 5 months None
8 Male 50 22.5 R Fracture of the tibia Attune 0–135 15 months PJI at 4 months post-op effectively treated with I&D with polyethylene exchange at 1-year post-op
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a

Limited by suspected osteoarthritis of the hip.

Moreover, there were no early complications in seven patients. One patient reported medial pain at the one-month follow-up visit, but this resolved in one week. The only major complication in this cohort was an acute prosthetic infection at four months post-operative, most likely due to a previous spine infection. This infection was suspected to be a result of hematogenous spread given the infection occurred temporally after the discitis, and the patient had a blood culture positive for Group B strep prior to presentation with the PJI and had the acute onset of pain. This patient was successfully treated with irrigation and debridement with polyethylene exchange and six weeks of intravenous antibiotics. Radiographs were evaluated by all authors. None of the most recent radiographs for the patients in the cohort demonstrated any signs of migration or loosening (see Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6). Migration was defined as change in radiographic position of the implant with similar radiographic views. Loosening was defined as progressively increasing radiolucent lines, circumferential radiolucent lines, or clinically significant change in implant position associated with symptoms.

Fig. 1.

Fig. 1

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Case 1: 28 months post-op images depicting cementless fixation with history of tibial fracture.

Fig. 2.

Fig. 2

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Case 3: 1-year post-op image depicting cementless fixation with prior ACL screw.

Fig. 3.

Fig. 3

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Case 7: Preoperative images showing previous knee trauma.

Fig. 4.

Fig. 4

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Case 7: Post-operative images depicting cementless fixation.

Fig. 5.

Fig. 5

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Case 8: pre-revision images.

Fig. 6.

Fig. 6

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– Case 8: 3 months post-revision with polyethylene exchange.

4. Discussion

ACL injuries and other trauma such as proximal tibial fractures complicate TKA due to challenges related to soft tissue defects from scar formation, stiffness, and bony deformity.16 TKA in PTOA knees from fractures in either the distal femur or proximal tibia also demonstrates lower survival rates and higher revision rates when compared to TKA due to primary osteoarthritis.17 Interestingly, El-Galaly and colleagues found that highest cumulative failure rate was in their youngest age group (patients <50 years), and that younger age was highly associated with revision rates likely due to increased wear of the implant or lower thresholds for revision.17 In contrast, the average age in our cohort was 57.5 years and may partially explain differences in revision rates. Overall, post-traumatic osteoarthritis promotes cartilage degradation and a more unstable joint at an accelerated rate compared to primary osteoarthritis. Ultimately, this leads to more severe presentation and structural damage at the time of TKA compared to primary osteoarthritis. Despite increased complications overall in this patient population, the use of cementless fixation in revision surgeries, which is an analogous situation, has proven to be feasible. Specifically, there is usually a lack of remaining bone stock in these patients, and the use of cementless metaphyseal sleeve and cone fixation has demonstrated osseous in-growth and excellent clinical outcomes.18, 19, 20, 21 Numerous studies have shown that the use of cementless fixation has improved outcomes of post-traumatic hip arthroplasty after failed internal fixation.22, 23, 24 Further, cementless primary fixation has been utilized in a variety of patient populations, ages, bone quality and demographics with successful results.2, 3, 4, 5, 6 Advantages of cementless fixation included quicker surgery, potentially preserved bone stock, and dynamic durable fixation in a younger patient population.25 Although most patients included in our study had a BMI >30, the use of a cementless implant was guided by multiple factors with history of trauma and prior hardware weighed most heavily. However, the positive outcomes in this cohort support the existing evidence for use of cementless implants in individuals with obesity. In both people with obesity and PTOA patients with limited bone stock, the cementless implant can support increased bony ingrowth and ultimately stability of the knee.3,4

While a history of ACL reconstruction may lead to decreased post-operative ROM at one year compared to preoperative, there are mixed results on the complication rates for this patient population.26, 27, 28 A recent meta-analysis of seven studies by Alessio-Mazzola et al. (2023) found that the complication rates of post-ACL TKA were significantly higher than control groups and that post-ACL knees required increased use of revision components.27 With the prior tibial screw fixation surgeons may choose to stem to the tibial component to bypass the screw tract and to offer additional tibial fixation. This analysis also found that post-ACL repair knees were likely to experience stiffness and increased rates of infection and reoperation.27 Overall, the most common reason for revision in PTOA knees in general is instability and arthrofibrosis whereas the most common cause in patients with osteoarthritis is patellar pain 29. Despite these potential complications, no significant difference in rates of arthrofibrosis has been demonstrated in recent studies comparing cemented and cementless supporting the finding that cementless fixation is a safe option for post-ACL knees.30 However, there is minimal published data on cementless fixation in the post-ACL TKA.

Additionally, there is consensus that patients with a history of prior knee surgery who undergo TKA, often referred to as conversion total knee arthroplasty (convTKA), are at increased risk of postoperative infection.30 In addition to higher risk of reoperation and increased operative time, this procedure type also has higher rates of blood transfusions, re-admissions, and overall resource utilization.32, 33, 34, 35 Although it is too early to determine the long-term survivorship of the implants in this study, the lack of acute complications in this cohort is notable as migration or loosening of cementless implants usually happen within the first year.36 However, one of the eight patients did have a rare post-operative infection, which is consistent with this patient population having higher complication and infection rates.31 Therefore, a broad-spectrum prophylactic antibiotic regimen or post-op antibiotics may be a strategy to decrease infections in the PTOA patient population.

This study has several limitations. The majority of the TKAs performed at this academic, tertiary referral center from 2020 to 2024 were cemented. Therefore, the sample size is small particularly for TKAs in patients with history of trauma or ACL repair. Furthermore, there is potential for bias given the patient's medical history, current health status, and risk factors were likely considered prior to use of cementless implants. In particular, the patients in this sample had varying types of knee trauma including ACL injury, closed fracture of the patella, tibial fractures, and distal femur fracture. The type of previous surgery and the extent of tissue varies between these types of injuries. The extent of tissue injury and bone stock as well as perceived low risk of complications likely influenced use of cementless implants in these patients and contributed to overall positive outcomes. Furthermore, while the number of cementless implants used has increased over the past few years at this institution, the follow-up time for patients is still very limited. In particular, early stability is not an indicator of potential long-term stability in PTOA as there is poor bone stock and possible instability from prior fracture hardware.17 Long-term follow-up, at least 2–5 years post-op in these patients, is necessary to better assess survivorship of the cementless implants in PTOA and determine the extent of osseointegration.

Furthermore, another confounding factor in this study may be the type of cementless implant used. Although six out of eight implants were Attune Cementless CR, there were two other systems used, the Djo EMPOWR and the Stryker Triathlon, which may be a potential source of bias. More rigorous analysis of differences in radiolucency and revision rates at long-term follow-up would be needed to discern whether implant type influenced cementless TKA outcomes in the patient population. Given the small sample size and uncontrolled variation due to inclusion of cases performed by two different surgeons, any differences in outcomes due to implant type cannot be analyzed in the present study. Therefore, the heterogeneity of implants is a key limitation and prevents direct comparison of outcomes among the patients in our cohort. Lastly, patient-reported outcomes, such as the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) or the Knee Injury and Osteoarthritis Outcome Score (KOOS), were not collected pre- or post-operatively limiting insight into how the cementless implants impacted function and quality of life for the patients in this cohort. Future studies including data on patient reported outcomes are needed to better characterize the patient type that would benefit from cementless implants. Despite these limitations, this study provides some insight into the safety of cementless implants and contributes to the dearth of literature on the post-trauma or post-ACL repair knees. Continued follow-up is essential to understand long-term outcomes of cementless TKA, especially given the younger mean age at the time of surgery in this patient population.

5. Conclusion

These cases demonstrate the short-term safety of cementless fixation for TKA in in post-ACL and post-traumatic knees.

Ethics approval

Exempted.

Credit author Statement

Maha L Khan: Methodology, formal analysis, data curation, investigation, writing – original draft, writing – review and editing.

Sara Winfrey: Methodology, data curation, investigation, writing – review and editing.

Nicholas Brown: Conceptualization, Methodology, validation, investigation, writing – original draft, writing – review and editing, supervision, project administration.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

none.

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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