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Cementless knee implants are no longer a niche option for orthopedic companies. A growing number of surgeons are using the implants in total knee arthroplasty (TKA), especially for younger, active patients. According to the AAOS American Joint Replacement Registry, cementless fixation was used in 22% of primary TKAs in 2023, up from 2% in 2012.
Several factors are contributing to the increased interest in cementless fixation.
Patient Outcomes. Surgeons want implants that last longer and better handle the demands of active lifestyles. Cementless implants have shown strong clinical performance, particularly as technologies like 3D printing improve surface integration.
“The growing TKA volumes in younger patients has increased the interest in durable fixation that can better accommodate higher activity levels and potentially reduce revision rates later in life,” said Jordan Wagner, Vice President of Marketing at restor3d. “Those are things cementless designs are well-positioned to address.”
Biological surfaces and implant designs aimed at better fixation have also led to improved outcomes, which has increased interest in cementless designs, according to Joe Urban, Global President of Zimmer Biomet’s Knee Business.
Cementless systems also reduce risks tied to cement use, such as thermal necrosis and third-body wear.
Peter Cipolletti, Senior Director of Marketing at Exactech, said bone preservation depends on more than just the fixation method but noted that newer cementless systems use a cylindrical box resection that requires the removal of 30% less bone than traditional designs.
Improved Surface Technology. Successful cementless fixation depends on surface design.
Zimmer Biomet uses OsseoTi porous metal to mimic cancellous bone and promote early fixation. The company’s PPS coating is designed to promote initial scratch-fit stability and long-term biologic fixation.
restor3d uses fully 3D-printed TIDAL Technology to replicate bone, support integration and promote consistent biologic fixation.
Exactech has moved beyond coatings like hydroxyapatite. Cipolletti said additive manufacturing (AM) allows for better pore geometry and bone ingrowth.
Advances in AM and surface engineering have improved implant fixation and bone integration, making cementless options more viable.
AM enables precise control of porosity and surface architecture, allowing for better design flexibility and more effective biological response. “The technology has fundamentally changed how we design cementless implants,” Wagner said.
Urban explained that Zimmer Biomet now builds monolithic components with laser sintering, improving their structural integrity. “The component can be produced from top to bottom as one continuous piece,” he said.
Cipolletti acknowledged that designing for strength and porosity required iteration and close collaboration between engineers and surgeons. “Striking the balance between strength and porosity was particularly challenging,” he said.
Surgical Efficiency. Cementless implants also offer shorter operating times. Urban said cementless TKA procedures are up to 11 minutes faster than cemented ones.
These implants reduce surgical time by eliminating cement mixing and curing steps, which helps streamline procedures and lower costs.
The reduction in O.R. time and procedure simplification is especially important in outpatient surgery environments. “These factors offer potential workflow efficiencies and cost savings,” Wagner said.
Cipolletti added that as more TKAs move to outpatient settings, the need for efficient, cement-free systems will increase.
Design Flexibility. Zimmer Biomet’s Persona OsseoTi Keel Tibia allows surgeons to switch from cementless to cemented fixation mid-procedure without changing bone prep. Urban said this gives surgeons flexibility without compromising outcomes.
“Surgeons can make an intraoperative decision based on the best fixation for their patient, even if it means making a change to the preoperative plan,” he added.
Zimmer Biomet also builds for different patient needs, including metal sensitivities and micromotion concerns. “With 3D printing capabilities, we can manufacture to meet the growing demand of our cementless solutions,” Urban said.
Exactech focuses on integration between implant design and surgical planning. Cipolletti said design choices go beyond surface coatings to include how the implant interacts with supporting materials and how procedures are executed.
Looking Ahead
The future of cementless knees looks strong. Surgeons are gaining experience, patient demand is growing and AM continues to create new design possibilities.
“Recent registry data and peer-reviewed studies have shown comparable or superior outcomes with cementless knees,” Wagner said. “As more surgeons gain experience and confidence with newer systems, adoption is steadily increasing.”
Read more about these topics in the full-length version of this article.
