The association between viscosity cement and revision risk following primary total knee arthroplasty

Abstract Introduction Recent case series have reported early failure with the use of high viscosity cement (HVC) in total knee arthroplasty (TKA). We evaluated revision risk following TKA with HVC compared to medium viscosity cement (MVC) in a large cohort. Methods We conducted a cohort study using data from a United States integrated healthcare system’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 three highest-volume implant systems (DePuy PFC, Zimmer Nexgen, 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 TKA, 41.1% using MVC. The crude 14-year cumulative revision probability was 4.55% and 5.12% for TKA with MVC and HVC. In propensity score-weighted Cox models, MVC compared to HVC had a lower risk of any revision (hazard ratio [HR]=0.82, 95% confidence interval [CI]=0.70-0.95) while no difference was observed for revision from aseptic loosening (HR=0.80, 95% CI=0.56-1.13). Conclusion While we observed a lower risk for any revision with the use of Simplex MVC compared to 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