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The Association Between Cement Viscosity and Revision Risk After Primary Total Knee Arthroplasty


J Arthroplasty. 2021 Jan 27;S0883-5403(21)00092-9. doi: 10.1016/j.arth.2021.01.052.Online ahead of print.

Ronald W B Wyatt 1Richard N Chang 2Kathryn E Royse 2Elizabeth W Paxton 2Robert S Namba 3Heather A Prentice 2

Author Information

1 Department of Orthopaedics, The Permanente Medical Group, Walnut Creek, CA.

2 Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA.

3 Department of Orthopaedics, Southern California Permanente Medical Group, Irvine, CA.


Background: Recent case series have reported early failure with the use of high-viscosity cement (HVC) in total knee arthroplasty (TKA). We evaluated revision risk after TKA with HVC compared with medium-viscosity cement (MVC) in a large cohort.

Methods: We conducted a cohort study using data from Kaiser Permanente's Total Joint Replacement Registry. Patients who underwent fully cemented primary TKA for osteoarthritis were identified (2001-2018). Only posterior-stabilized, fixed-mobility designs of the 3 highest-volume implant systems (DePuy PFC, Zimmer NexGen, and Zimmer Persona) were included to mitigate confounding from implant characteristics. Palacos (Zimmer/Heraeus) and Simplex (Stryker) cements comprised the HVC and MVC exposure groups, respectively. Propensity score-weighted Cox proportional hazards regression was used to evaluate risk for any revision during follow-up and risk for revision from aseptic loosening specifically.

Results: The final cohort comprised 76,052 TKAs, 41.1% using MVC. The crude 14-year cumulative revision probability was 4.55% and 5.12% for TKA with MVC and HVC, respectively. In propensity score-weighted Cox models, MVC compared with HVC had a lower risk of any revision (hazard ratio = 0.82, 95% confidence interval = 0.70-0.95) while no difference was observed for revision from aseptic loosening (hazard ratio = 0.80, 95% confidence interval = 0.56-1.13).

Conclusion: While we observed a lower risk for any revision with the use of Simplex MVC compared with Palacos HVC, we did not observe a difference in revision for aseptic loosening specifically. Given the widespread use of HVC, additional research to investigate other HVC and potential mechanisms for failure outside of loosening is warranted.

Level of evidence: Level III.