Similar clinical and survival outcomes between robotic-assisted cemented and cementless total knee arthroplasty

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Robotic assistance may improve the accuracy of cementless implantation and promote favorable outcomes. Methods: A retrospective review was conducted of 130 cruciate-retaining primary TKAs performed using the ROSA® robotic-assisted system between October 2021 and September 2023 by a single high-volume surgeon. Patients received either a cementless Persona Trabecular Metal® (n = 80) or cemented Persona® (n = 50) prosthesis. Patient demographics, perioperative data, complications, and revisions were recorded. Patient-reported outcome measures (PROMs) WOMAC, Oxford Knee Score, Knee Society Score, and Forgotten Joint Score-12 were collected preoperatively and at minimum one-year follow-up. Results: Patients in the cementless group were younger (p < 0.001) and more frequently men (p = 0.003). Both groups showed significant improvement in all PROMs from baseline (p < 0.001), with no statistically significant differences in final PROMs between groups. One revision occurred in the cemented group (2.0%) due to stiffness and pain; two manipulations under anesthesia (MUA) were required in the cementless group (2.5%). No differences were observed in operative time or hospital length of stay. Conclusion: At short-term follow-up, cementless and cemented robotic-assisted TKAs demonstrated equivalent improvements in PROMs and survivorship. Cementless implants may represent a viable option in appropriately selected patients, particularly younger individuals, when combined with robotic precision. Long-term data are needed to confirm durability. Total knee arthroplasty cemented fixation cementless fixation robotic-assisted surgery ROSA® Knee System PROMs aseptic loosening short-term outcomes. Introduction Total knee arthroplasty (TKA) procedures have been steadily increasing over the years, and current projections estimate that the annual number of procedures performed in the United States will continue to rise through 2030. [ 1 ] A corresponding rise in revision total knee arthroplasty (rTKA) procedures is to be expected. [ 2 ] Aseptic loosening has emerged as a major contributor to TKA revision, accounting for 24.4% of all revision surgeries performed in the United States from 2012 to 2023. [ 3 ] Risk factors such as age and body mass index (BMI) have been shown to influence the incidence of aseptic loosening. Specifically, younger individuals and those with a high BMI are at a heightened risk. [ 4 ] Currently, there is no consensus on the optimal fixation technique of TKA. [ 5 ] Cemented fixation remains the gold standard today, supported by long-term survival rates reported in the literature. [ 6 ] [ 7 ] [ 8 ] [ 9 ] However, its well-documented longevity may be compromised particularly in younger and more active patients [ 10 ] [ 11 ]: a demographic that is steadily growing and projected to increase further in the coming years. [ 12 ] [ 13 ] Young age and high BMI are risk factors for cemented TKA failure, as the bone-cement interface is more likely to fail with increased cyclical loading. [ 14 ] [ 15 ] The absence of a bone–cement interface in cementless fixation promotes osseointegration and reduces the implant’s vulnerability to mechanical stress, making it an attractive alternative. [ 16 ] Data from the American Joint Replacement Registry indicate that cementless fixation was employed in 22% of all primary TKA procedures performed in 2023, a substantial increase from 1.9% in 2012. [ 3 ] Despite the advantages of cementless fixation, the absence of cement necessitates a meticulous surgical technique to ensure successful osseointegration and long-term implant survivorship. [ 17 ] The ROSA® (Robotic Surgical Assistant) Knee System (Zimmer Biomet, Warsaw, IN) is a robotic platform that integrates ligament balancing assessment with robotic placement of cutting guides in a collaborative workflow. Both in vivo and cadaveric studies have demonstrated its high cutting accuracy and excellent reproducibility. [ 18 ] [ 19 ] [ 20 ] [ 21 ] [ 22 ] The aim of this study was to evaluate the short-term clinical outcomes and implant survivorship of cementless TKA in comparison with cemented implants. The central hypothesis posited that the absence of cement reduces the risk of aseptic loosening and that the precision afforded by robotic assistance further optimizes the positioning of cementless components, thereby contributing to improved implant survivorship. To the best of our knowledge, this is the first study to investigate the outcomes and survivorship of cemented versus cementless TKAs performed using the ROSA® robotic assistance system. This retrospective, single-surgeon, single-center study compares the short-term outcomes and survivorship of cemented and cementless TKAs executed with robotic assistance. We hypothesize that cementless TKAs are not inferior to their cemented counterparts. Material and Methods Patient Selection This retrospective study analyzed a cohort of patients who underwent cruciate-retaining (CR) total knee arthroplasty (TKA) using either a cementless Persona Trabecular Metal® (TM) prosthesis or a cemented Persona® prosthesis (Zimmer Biomet, Warsaw, IN, USA), all performed with robotic assistance using the ROSA® Knee System (Zimmer Biomet, Warsaw, IN, USA). All procedures were carried out by a single high-volume senior surgeon (F.D.A.) at a single institution between October 2021 and September 2023. Clinical data were extracted from the hospital’s information system and stored in a secure, restricted-access database. Patients were eligible for inclusion if they had a minimum follow-up of one year and had provided written informed consent. Exclusion criteria included concurrent knee surgeries at the time of TKA, bilateral procedures, or refusal to consent. The study was conducted in accordance with the Declaration of Helsinki and good clinical practice guidelines. The study protocol was approved by the Ethics Committee of Humanitas Research Hospital (protocol code 618/17). Written informed consent was obtained from all participants prior to data collection. Patients’ data and PROMs Data extracted from the institutional database encompassed demographic information, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, surgical procedure duration, length of hospital stay, occurrence of surgical revisions, and any intraoperative, perioperative, or postoperative complications. Patient reported outcome measures (PROMs) were collected preoperatively and at the final follow-up. These included Western Ontario and McMaster University Osteoarthritis Index (WOMAC) [ 23 ], Knee Society Knee Scoring System [ 24 ], Oxford Knee Score [ 25 ] and Forgotten Joint-Score 12 [ 26 ]. Surgical technique All patients included in this study underwent primary cruciate-retaining total knee arthroplasty (CR-TKA) performed by a single, highly experienced surgeon (F.D.A.) at a single center. Preoperatively, all patients received intravenous antibiotic prophylaxis consisting of either 2 grams of cefazolin or 600 milligrams of clindamycin. A sterile surgical field was established using disposable drapes, and the ROSA® robotic system was positioned and configured accordingly. A minimally invasive mini-mid vastus medial parapatellar approach was employed for all patients. [ 27 ] Bone resections and ligament balancing were performed according to the ROSA® imageless protocol, following the principles of functional alignment. [ 28 ] [ 29 ] [ 30 ] Implant selection (cemented vs. cementless) was determined preoperatively based on imaging studies; however, intraoperative assessment of bone quality could lead to a change in the chosen fixation method if suboptimal bone stock was identified. To minimize blood loss, 1 gram of tranexamic acid was administered intravenously at the time of incision, followed by an additional 3 grams injected intra-articularly after capsule closure, when deemed clinically appropriate. Skin closure was performed with absorbable subcuticular sutures. No tourniquet was used during any of the procedures Post-operative management Following surgery, all patients received a regional analgesic block to facilitate postoperative pain management. A standardized analgesic protocol was implemented to support early mobilization, ideally beginning on the day of surgery. An in-patient physiotherapy program was initiated immediately to improve joint range of motion and muscle strength. Patients also received instruction on the appropriate use of crutches. When clinically appropriate, patients were discharged to continue their rehabilitation at home under the supervision of a licensed physical therapist. Follow-up evaluations were scheduled at 1, 3, 6, and 12 months postoperatively, with annual assessments thereafter. To prevent deep vein thrombosis, low-molecular-weight heparin was prescribed for approximately five weeks. Data Analyses All statistical analyses were performed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA). For continuous variables, the choice of test depended on the sample size. When the sample size was less than 20, between-group comparisons were conducted using the Two-Sample Wilcoxon Test, while changes from baseline were assessed using the Wilcoxon Signed-Rank Test. For sample sizes greater than or equal to 20, the Independent Samples t-Test was employed for between-group comparisons, and the Paired Samples t-Test was used to evaluate within-group changes from baseline. For categorical variables, the statistical method was selected based on the assumptions of the Chi-Square Test. Specifically, this test was applied when at least 80% of the expected cell counts were ≥ 5, and no cell had an expected count < 1. If these assumptions were violated, the Fisher’s Exact Test was used instead Results Baseline characteristics The demographic and surgical characteristics of both cohorts are summarized in Table 1 and Table 2 . A total of 130 cruciate-retaining TKAs were included in the analysis, comprising 80 patients who received the cementless Persona® Trabecular Metal™ (TM) implant and 50 patients who received the cemented Persona® implant. Patients in the TM group were significantly younger than those in the cemented group, and the proportion of men patients was significantly higher in the TM group. No other statistically significant demographic differences were observed between the two groups. There were no statistically significant differences between the groups with respect to operative time, number of transfusions, or length of hospital stay Table 1 Demographics Cemented N = 50 Persona TM N = 80 P-Value Age (years) 74.6 ± 9.0 69.7 ± 8.2 T-test (Pooled): P = 0.0018 BMI 28.9 ± 5.1 28.4 ± 4.8 T-test (Pooled): P = 0.5800 Gender Men 30.0% (15/50) 53.8% (43/80) Likelihood Ratio Chi Square test: P = 0.0074 Women 70.0% (35/50) 46.3% (37/80) ASA Grade 1 16.0% (8/50) 16.3% (13/80) Likelihood Ratio Chi Square test: P = 0.9943 2 76.0% (38/50) 76.3% (61/80) 3 8.0% (4/50) 7.5% (6/80) Surgery Side Left 42.0% (21/50) 47.5% (38/80) Likelihood Ratio Chi Square test: P = 0.5396 Right 58.0% (29/50) 52.5% (42/80) Surgical Information Cemented N = 50 Persona TM N = 80 P-Value Operative Time (skin to skin, minutes) 86.2 ± 17.5 82.4 ± 18.8 T-test (Pooled): P = 0.2454 Number of Transfused Bags 0 100.0% (50/50) 98.8% (79/80) Fisher Exact test: P = > 0.9999 4 0.0% (0/50) 1.3% (1/80) Length of Stay (days) 6.0 ± 2.2 5.5 ± 2.0 T-test (Pooled): P = 0.2350 Table 2 Clinical Scores Cemented N = 50 Persona TM N = 80 P-Value between groups WOMAC Score (%) Pre-op 50.5 ± 15.0 (20.0, 48.0, 80.0) 95% C.I. (46.3, 54.8) 45.8 ± 16.3 (14.0, 47.0, 80.0) 95% C.I. (42.2, 49.4) T-test (Pooled): P = 0.0985 1 year 14.2 ± 13.5 (0.0, 11.0, 58.0) 95% C.I. (10.4, 18.0) 13.8 ± 12.3 (0.0, 13.0, 50.0) 95% C.I. (11.1, 16.6) T-test (Pooled): P = 0.8752 P-Value Paired T-Test: P = < .0001 Paired T-Test: P = < .0001 KSS Symptoms Pre-op 6.1 ± 4.0 (0.0, 7.5, 14.0) 95% C.I. (5.0, 7.3) 7.4 ± 3.6 (0.0, 8.0, 17.0) 95% C.I. (6.6, 8.2) T-test (Pooled): P = 0.0620 1 year 19.7 ± 5.1 (4.0, 21.0, 25.0) 95% C.I. (18.2, 21.1) 20.1 ± 5.3 (3.0, 21.0, 25.0) 95% C.I. (18.9, 21.3) T-test (Pooled): P = 0.6387 P-Value Paired T-Test: P = < .0001 Paired T-Test: P = < .0001 KSS Satisfaction Pre-op 11.8 ± 8.2 (0.0, 10.0, 32.0) 95% C.I. (9.4, 14.1) 12.2 ± 6.9 (0.0, 10.0, 40.0) 95% C.I. (10.6, 13.7) T-test (Pooled): P = 0.7629 1 year 28.8 ± 9.7 (0.0, 30.0, 40.0) 95% C.I. (26.1, 31.6) 27.5 ± 8.7 (0.0, 30.0, 40.0) 95% C.I. (25.5, 29.4) T-test (Pooled): P = 0.4015 P-Value Paired T-Test: P = < .0001 Paired T-Test: P = < .0001 KSS Expectation Pre-op 12.1 ± 2.0 (8.0, 12.0, 15.0) 95% C.I. (11.5, 12.7) 11.0 ± 1.9 (6.0, 11.0, 15.0) 95% C.I. (10.6, 11.4) T-test (Pooled): P = 0.0030 1 year 9.6 ± 2.3 (3.0, 9.0, 15.0) 95% C.I. (9.0, 10.3) 9.7 ± 1.8 (6.0, 10.0, 15.0) 95% C.I. (9.3, 10.1) T-test (Satterthwaite): P = 0.8339 P-Value Paired T-Test: P = < .0001 Paired T-Test: P = < .0001 KSS Function Pre-op 55.0 ± 17.7 (0.0, 53.0, 89.0) 95% C.I. (50.0, 60.1) 54.2 ± 16.5 (18.0, 55.5, 82.0) 95% C.I. (50.5, 57.9) T-test (Pooled): P = 0.7834 1 year 76.8 ± 16.3 (7.0, 81.0, 100.0) 95% C.I. (72.2, 81.4) 79.6 ± 12.5 (43.0, 81.0, 100.0) 95% C.I. (76.8, 82.3) T-test (Satterthwaite): P = 0.3114 P-Value Paired T-Test: P = < .0001 Paired T-Test: P = < .0001 OKS Pre-op 26.4 ± 7.6 (10.0, 26.0, 40.0) 95% C.I. (24.3, 28.5) 26.5 ± 7.9 (10.0, 26.0, 40.0) 95% C.I. (24.7, 28.2) T-test (Pooled): P = 0.9715 1 year 42.1 ± 6.5 (22.0, 44.0, 48.0) 95% C.I. (40.2, 43.9) 42.1 ± 6.1 (24.0, 42.0, 48.0) 95% C.I. (40.8, 43.5) T-test (Pooled): P = 0.9683 P-Value Paired T-Test: P = < .0001 Paired T-Test: P = < .0001 FJS 1 year 78.8 ± 17.9 (18.8, 82.9, 100.0) 95% C.I. (73.7, 83.9) 80.7 ± 15.9 (27.1, 83.3, 100.0) 95% C.I. (77.2, 84.3) T-test (Pooled): P = 0.5163 Patient-reported outcomes After a minimum of 1 year of follow-up, statistically significant improvements were observed in all proposed PROMs for both cohorts. However, no significant differences were found between the two groups. These results are showed in Table 3 . Table 3 Survival Rate Group N Revised N Cases Survival Rate Aseptic loosening Cemented 0 50 100% [130/130] Persona TM 0 80 100% [130/130] Every cause of revision Cemented 1 50 98% [49/50] Persona TM 0 80 100% [80/80] Return to the operating room Cemented 1 50 98% [49/50] Persona TM 2 80 97.5% [78/80] Table 4 Demographics Cemented N = 50 Persona TM N = 80 P-Value Age (years) 74.6 ± 9.0 69.7 ± 8.2 T-test (Pooled): P = 0.0018 BMI 28.9 ± 5.1 28.4 ± 4.8 T-test (Pooled): P = 0.5800 Gender Men 30.0% (15/50) 53.8% (43/80) Likelihood Ratio Chi Square test: P = 0.0074 Women 70.0% (35/50) 46.3% (37/80) ASA Grade 1 16.0% (8/50) 16.3% (13/80) Likelihood Ratio Chi Square test: P = 0.9943 2 76.0% (38/50) 76.3% (61/80) 3 8.0% (4/50) 7.5% (6/80) Surgery Side Left 42.0% (21/50) 47.5% (38/80) Likelihood Ratio Chi Square test: P = 0.5396 Right 58.0% (29/50) 52.5% (42/80) Surgical Information Cemented N = 50 Persona TM N = 80 P-Value Operative Time (skin to skin, minutes) 86.2 ± 17.5 82.4 ± 18.8 T-test (Pooled): P = 0.2454 Number of Transfused Bags 0 100.0% (50/50) 98.8% (79/80) Fisher Exact test: P = > 0.9999 4 0.0% (0/50) 1.3% (1/80) Length of Stay (days) 6.0 ± 2.2 5.5 ± 2.0 T-test (Pooled): P = 0.2350 Survivorship and Complications Among the 130 TKAs included in this study, one patient in the cemented cohort required revision surgery due to postoperative stiffness and pain, which occurred six months after the index procedure. The revision involved patellar resurfacing and polyethylene insert exchange, resulting in pain resolution and restoration of full range of motion. In the cementless cohort, two patients developed postoperative stiffness and subsequently underwent manipulation under anesthesia (MUA) at five and three months postoperatively, respectively. Both cases resulted in successful recovery of full range of motion. Implant survival rates are presented in Table 3 . One patient in the cemented group experienced significant intraoperative blood loss and required postoperative transfusion of four units of packed red blood cells. No other patients in either cohort required transfusion. Discussion In this retrospective study comparing cemented and cementless cruciate-retaining total knee arthroplasties (CR-TKAs) performed with robotic assistance using the ROSA® Knee System, no statistically significant differences were observed in patient-reported outcome measures (PROMs) or short-term implant survivorship between the two groups. Both cohorts demonstrated significant postoperative improvements across all PROMs, with comparable rates of complications and returns to the operating room. The cementless cohort, which primarily consisted of younger men patients, experienced no revisions during the follow-up period, whereas one revision was recorded in the cemented group. These findings support the clinical viability of cementless implants in appropriately selected patients and underscore the potential value of robotic assistance in enhancing surgical accuracy, particularly in cementless fixation, where precision is critical for successful osseointegration. Although the clinical outcomes of cementless implants were considered suboptimal in earlier generations [ 31 ] [ 32 ] [ 33 ] [ 34 ] [ 35 ], advancements in biomaterials and implant design have endowed the current generation with promising potential for long-term durability and performance.[ 36 ] While cemented fixation remains the most commonly used technique in total knee arthroplasty (TKA), the adoption of cementless fixation has steadily increased, now accounting for over 20% of all procedures. [ 3 ] This shift is largely driven by the rising demand for TKA, which has led to a broader patient demographic, including a growing proportion of younger and more physically active individuals.[ 37 ] Cementless fixation is often preferred in younger patients due to the presence of a direct bone–implant interface, which may offer more durable and long-lasting fixation compared to cemented implants. This approach reduces the risk of loosening secondary to osteolysis or third-body wear associated with cement debris and may facilitate easier revision surgery by minimizing bone loss.[ 38 ] As reflected in the demographic findings of our cohort, cementless prostheses are primarily utilized in younger patients and mens. Currently, survivorship data for cementless implants in femen patients over the age of 65 remain inconclusive, leading many surgeons to refrain from recommending this fixation method in this population. [ 3 ] To the best of our knowledge, this is the first study to evaluate the clinical outcomes of the ROSA® Knee System robotic technology in a cohort including both cemented and cementless total knee arthroplasties. Precise bone cutting is critical to reducing the risk of failure in cementless prosthesis implantation. [ 39 ] [ 40 ] Therefore, the use of robotic technology, which significantly enhances the accuracy of cuts [ 41 ] [ 42 ] [ 43 ], compared to traditional techniques, could be beneficial for the cementless prosthesis. Our results demonstrate significant improvements in patient-reported outcome measures (PROMs) from the preoperative to postoperative period in both groups, with no statistically significant differences observed between the cemented and cementless cohorts. These findings suggest that, in the short term, both implant types yield comparable clinical outcomes. Moreover, our results are consistent with previously published studies comparing cemented and cementless total knee arthroplasties performed with robotic assistance. [ 44 ] [ 45 ] In the study by Molho et al., 335 cementless implants were compared with 247 cemented implants, demonstrating comparable short-term patient-reported outcome measures (PROMs), but a significantly higher rate of return to the operating room in the cemented group. [ 46 ] In our study, the rate of return to the operating room did not reach statistical significance. Similarly, the results of McCormick et al. demonstrated equivalent PROMs in the short term between the cemented and cementless cohort. [ 47 ] Given the comparable outcomes observed between the two implant types, we believe that selecting cementless implants for appropriately indicated patients is critical to improving long-term implant survivorship and reducing the risk of aseptic loosening. Furthermore, the potential time and cost savings associated with cementless techniques may offer additional advantages, particularly in high-volume surgical settings. [ 48 ] [ 49 ] can make them a more economical alternative. Although the TM group demonstrated a shorter mean operative time in our study, the difference was not statistically significant. We hypothesize that this result may be influenced by the relatively small sample size and the learning curve associated with the adoption of robotic-assisted surgery in our institution, which began in 2020. Given the short-term nature of this study, substantial differences in implant survivorship between the two cohorts were not anticipated. Consistent with this expectation, we observed only three returns to the operating room and a single revision procedure. One patient in the cemented group required revision surgery due to persistent pain and stiffness, which was managed with polyethylene insert exchange and patellar resurfacing. The other two returns to the operating room involved cases of stiffness in the cementless group; both were successfully treated with manipulation under anesthesia (MUA), resulting in improved range of motion. These findings are highly consistent with existing literature on both robotically assisted and conventionally performed total knee arthroplasty procedures. [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ]. Several limitations inherent to this study should be acknowledged. First, the procedures were performed by a single surgeon at a single institution, which may limit the generalizability of the findings to broader clinical practice. Second, the retrospective study design introduces inherent methodological limitations, including potential selection bias. The method of fixation was not randomly assigned, thereby precluding definitive conclusions regarding the universal applicability of cementless fixation in TKA patients. Moreover, the relatively short duration of follow-up may not fully capture long-term differences in outcomes between the two groups. Ongoing surveillance and future prospective, randomized studies with longer follow-up are warranted to better define optimal patient selection criteria and to evaluate the long-term performance of cemented versus cementless fixation methods. Conclusion This short-term comparison of cruciate-retaining total knee arthroplasty (CR-TKA) using cemented Persona® and cementless Persona® Trabecular Metal™ implants, both performed with robotic assistance, revealed no statistically significant differences in patient-reported outcome measures (PROMs) or implant survivorship. In appropriately selected patients, cementless fixation may represent a viable alternative, potentially reducing the risk of aseptic loosening and lowering long-term healthcare costs. The adoption of robotic systems may provide a distinct advantage in achieving optimal surgical precision, particularly in cementless procedures where accurate component alignment is critical for long-term success. Declarations Funding statement The author declares that no funding was received or utilized for the preparation, research, or writing of this paper. Author Contribution All authors contributed to the study conceptualization; methodology, U.V.; validation: F.D.A. and M.L.; formal analysis and investigation, U.V., F.D.D., M.A., and L.R.; writing—original draft preparation, U.V.; writing—review and editing, F.D.A. and M.L.; supervision, F.D.A. and M.L. All authors have read and agreed to the published version of the manuscript. Data Availability The data can be found in the following online database: Zenodo DOI: 10.5281/zenodo.15755384 References Kurtz S, Ong K, Lau E, Mowat F, Halpern eM (2007) «Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030», J. Bone Joint Surg. 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Orthop. , fasc. 356, pp. 66–72, nov. 10.1097/00003086-199811000-00011 Polizzotti G, Lamberti A, Mancino F, Baldini eA (2023) «New Horizons of Cementless Total Knee Arthroplasty», J. Clin. Med. , vol. 13, fasc. 1, p. 233, dic. 10.3390/jcm13010233 Chen C, Li eR (2019) «Cementless versus cemented total knee arthroplasty in young patients: a meta-analysis of randomized controlled trials», J. Orthop. Surg. , vol. 14, fasc. 1, p. 262, ago. 10.1186/s13018-019-1293-8 Mosher ZA, Bolognesi MP, Malkani AL, Meneghini RM, Oni JK (2024) e K. B. Fricka, «Cementless Total Knee Arthroplasty: A Resurgence-Who, When, Where, and How?», J. Arthroplasty , vol. 39, fasc. 9S2, pp. S45–S53, set. 10.1016/j.arth.2024.02.078 Aprato A, Risitano S, Sabatini L, Giachino M, Agati G, Massè eA (2016) «Cementless total knee arthroplasty», Ann. Transl. Med. , vol. 4, fasc. 7, p. 129, apr. 10.21037/atm.2016.01.34 Kamath AF, Lee G-C, Sheth NP, Nelson CL, Garino JP, Israelite eCL (2011) «Prospective results of uncemented tantalum monoblock tibia in total knee arthroplasty: minimum 5-year follow-up in patients younger than 55 years», J. Arthroplasty , vol. 26, fasc. 8, pp. 1390–1395, dic. 10.1016/j.arth.2011.06.030 Parratte S, Price AJ, Jeys LM, Jackson WF, Clarke eHD (2019) «Accuracy of a New Robotically Assisted Technique for Total Knee Arthroplasty: A Cadaveric Study», J. Arthroplasty , vol. 34, fasc. 11, pp. 2799–2803, nov. 10.1016/j.arth.2019.06.040 Rossi SMP, Sangaletti R, Perticarini L, Terragnoli F, Benazzo eF (2023) «High accuracy of a new robotically assisted technique for total knee arthroplasty: an in vivo study», Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA , vol. 31, fasc. 3, pp. 1153–1161, mar. 10.1007/s00167-021-06800-8 Seidenstein A, Birmingham M, Foran J, Ogden eS (2021) «Better accuracy and reproducibility of a new robotically-assisted system for total knee arthroplasty compared to conventional instrumentation: a cadaveric study», Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA , vol. 29, fasc. 3, pp. 859–866, mar. 10.1007/s00167-020-06038-w McCormick BP et al (2022) «Short-Term Outcomes Following Cemented Versus Cementless Robotic-Assisted Total Knee Arthroplasty», Cureus , vol. 14, fasc. 10, p. e30667, ott. 10.7759/cureus.30667 Molho D, Vaidya S, O’Sullivan D, Vye D, Nelson S (2024) e J. Bernstein, «Cemented vs Cementless Robotic-Assisted Total Knee Arthroplasty Yield Similar Short-Term Clinical Outcomes», Arthroplasty Today , vol. 27, p. 101360, giu. 10.1016/j.artd.2024.101360 Molho D, Vaidya S, O’Sullivan D, Vye D, Nelson S (2024) e J. Bernstein, «Cemented vs Cementless Robotic-Assisted Total Knee Arthroplasty Yield Similar Short-Term Clinical Outcomes», Arthroplasty Today , vol. 27, p. 101360, giu. 10.1016/j.artd.2024.101360 McCormick BP et al (2022) «Short-Term Outcomes Following Cemented Versus Cementless Robotic-Assisted Total Knee Arthroplasty», Cureus , vol. 14, fasc. 10, p. e30667, ott. 10.7759/cureus.30667 Lawrie CM, Schwabe M, Pierce A, Nunley RM, Barrack eRL (2019) «The cost of implanting a cemented versus cementless total knee arthroplasty», Bone Jt. J. , vol. 101-B, fasc. 7_Supple_C, pp. 61–63, lug. 10.1302/0301-620X.101B7.BJJ-2018-1470.R1 Yayac M, Harrer S, Hozack WJ, Parvizi J, Courtney ePM (2020) «The Use of Cementless Components Does Not Significantly Increase Procedural Costs in Total Knee Arthroplasty», J. Arthroplasty , vol. 35, fasc. 2, pp. 407–412, feb. 10.1016/j.arth.2019.08.063 McCormick BP et al (2022) «Short-Term Outcomes Following Cemented Versus Cementless Robotic-Assisted Total Knee Arthroplasty», Cureus , vol. 14, fasc. 10, p. e30667, ott. 10.7759/cureus.30667 Molho D, Vaidya S, O’Sullivan D, Vye D, Nelson S (2024) e J. Bernstein, «Cemented vs Cementless Robotic-Assisted Total Knee Arthroplasty Yield Similar Short-Term Clinical Outcomes», Arthroplasty Today , vol. 27, p. 101360, giu. 10.1016/j.artd.2024.101360 Puri S et al (2024) «Cementless Versus Cemented Total Knee Arthroplasty of the Same Design: Shorter Operative Times and Minimal Differences in Early Outcomes», HSS J. Musculoskelet. J. Hosp. Spec. Surg. , vol. 20, fasc. 2, pp. 202–207, mag. 10.1177/15563316231179220 Fricka KB, McAsey CJ, Sritulanondha eS (2019) «To Cement or Not? Five-Year Results of a Prospective, Randomized Study Comparing Cemented vs Cementless Total Knee Arthroplasty», J. Arthroplasty , vol. 34, fasc. 7S, pp. S183–S187, lug. 10.1016/j.arth.2019.02.024 Chen C, Li eR (2019) «Cementless versus cemented total knee arthroplasty in young patients: a meta-analysis of randomized controlled trials», J. Orthop. Surg. , vol. 14, fasc. 1, p. 262, ago. 10.1186/s13018-019-1293-8 Nam D, Lawrie CM, Salih R, Nahhas CR, Barrack RL, Nunley eRM (2019) «Cemented Versus Cementless Total Knee Arthroplasty of the Same Modern Design: A Prospective, Randomized Trial», J. Bone Joint Surg. Am. , vol. 101, fasc. 13, pp. 1185–1192, lug. 10.2106/JBJS.18.01162 Yazdi H, Choo KJ, Restrepo C, Hammad M, Sherman M, Parvizi eJ (2020) «Short-term results of triathlon cementless versus cemented primary total knee arthroplasty», The Knee , vol. 27, fasc. 4, pp. 1248–1255, ago. 10.1016/j.knee.2020.05.010 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Oct, 2025 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 01 Sep, 2025 Reviews received at journal 23 Aug, 2025 Reviewers agreed at journal 06 Aug, 2025 Reviewers invited by journal 25 Jul, 2025 Editor assigned by journal 17 Jul, 2025 Submission checks completed at journal 17 Jul, 2025 First submitted to journal 14 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7124562","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":490878152,"identity":"6535ee2a-325f-4601-ae23-8d6441f473a2","order_by":0,"name":"Umberto Vitale","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIie2PMUsDMRTHUx6cy2HWZPEzxOXqEHpf5YWDdDm7CKJU8KDQ0d1v4eTcELBL1a0IWU4KznWRcxFz9Tr17maH/CA88ng//u8REgj8S+Kmgn8lkbj74L7TqdQTAHXVjbLv9Cpkp9g/pS9GrJ/N5rqSRCyp2eLV60Ss7Uf5Xo1SckQXrYqbZKcr1ERYAIYrdyGcHgrETBUdiwmXJ7xAS/gMCFNzpx4cJgwRsOsWrwy/GwUq9fPilfGXV27THiUZ1AoFiJgqFl7J6xQ76FqM+1t4oXXsleQMnzJ17/JLhnqp5gCiTTl25+azkPIkombztr0ZqTs3fuSVnKaUmrI1piE+bEV984FAIBDo5RfDMVycYvn9wgAAAABJRU5ErkJggg==","orcid":"","institution":"Humanitas University","correspondingAuthor":true,"prefix":"","firstName":"Umberto","middleName":"","lastName":"Vitale","suffix":""},{"id":490878153,"identity":"2cbf4d8c-6416-4694-a182-9996aedd1129","order_by":1,"name":"Matteo Agarossi","email":"","orcid":"","institution":"Humanitas San Pio X","correspondingAuthor":false,"prefix":"","firstName":"Matteo","middleName":"","lastName":"Agarossi","suffix":""},{"id":490878154,"identity":"97e03a33-bdd3-4469-b0b8-dd75adc3aec5","order_by":2,"name":"Luca Ruosi","email":"","orcid":"","institution":"Humanitas University","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Ruosi","suffix":""},{"id":490878155,"identity":"01d3e65f-a811-4c4b-a0b4-364d3f4330df","order_by":3,"name":"Ferdinando De Dona","email":"","orcid":"","institution":"Humanitas University","correspondingAuthor":false,"prefix":"","firstName":"Ferdinando","middleName":"","lastName":"De Dona","suffix":""},{"id":490878156,"identity":"946e283d-3ed5-4a65-99d9-4e71dac2b6e1","order_by":4,"name":"Mattia Loppini","email":"","orcid":"","institution":"Humanitas University","correspondingAuthor":false,"prefix":"","firstName":"Mattia","middleName":"","lastName":"Loppini","suffix":""},{"id":490878157,"identity":"7eb8dd12-8d10-4307-8e78-5309338f3676","order_by":5,"name":"Federico D’Amario","email":"","orcid":"","institution":"Humanitas San Pio X","correspondingAuthor":false,"prefix":"","firstName":"Federico","middleName":"","lastName":"D’Amario","suffix":""}],"badges":[],"createdAt":"2025-07-14 21:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7124562/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7124562/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00402-025-06100-7","type":"published","date":"2025-10-24T16:17:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":94490782,"identity":"36ad2eb4-5076-4fbd-8755-68e38dbe59ac","added_by":"auto","created_at":"2025-10-27 17:15:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":769923,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7124562/v1/b0a09a4e-3369-4dcf-9a70-a04f3cc4fd8e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eSimilar clinical and survival outcomes between robotic-assisted cemented and cementless total knee arthroplasty\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal knee arthroplasty (TKA) procedures have been steadily increasing over the years, and current projections estimate that the annual number of procedures performed in the United States will continue to rise through 2030. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] A corresponding rise in revision total knee arthroplasty (rTKA) procedures is to be expected. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAseptic loosening has emerged as a major contributor to TKA revision, accounting for 24.4% of all revision surgeries performed in the United States from 2012 to 2023. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Risk factors such as age and body mass index (BMI) have been shown to influence the incidence of aseptic loosening. Specifically, younger individuals and those with a high BMI are at a heightened risk. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eCurrently, there is no consensus on the optimal fixation technique of TKA. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Cemented fixation remains the gold standard today, supported by long-term survival rates reported in the literature. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHowever, its well-documented longevity may be compromised particularly in younger and more active patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]: a demographic that is steadily growing and projected to increase further in the coming years. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Young age and high BMI are risk factors for cemented TKA failure, as the bone-cement interface is more likely to fail with increased cyclical loading. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe absence of a bone\u0026ndash;cement interface in cementless fixation promotes osseointegration and reduces the implant\u0026rsquo;s vulnerability to mechanical stress, making it an attractive alternative. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eData from the American Joint Replacement Registry indicate that cementless fixation was employed in 22% of all primary TKA procedures performed in 2023, a substantial increase from 1.9% in 2012. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Despite the advantages of cementless fixation, the absence of cement necessitates a meticulous surgical technique to ensure successful osseointegration and long-term implant survivorship. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe ROSA\u0026reg; (Robotic Surgical Assistant) Knee System (Zimmer Biomet, Warsaw, IN) is a robotic platform that integrates ligament balancing assessment with robotic placement of cutting guides in a collaborative workflow. Both in vivo and cadaveric studies have demonstrated its high cutting accuracy and excellent reproducibility. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe aim of this study was to evaluate the short-term clinical outcomes and implant survivorship of cementless TKA in comparison with cemented implants.\u003c/p\u003e\u003cp\u003eThe central hypothesis posited that the absence of cement reduces the risk of aseptic loosening and that the precision afforded by robotic assistance further optimizes the positioning of cementless components, thereby contributing to improved implant survivorship.\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this is the first study to investigate the outcomes and survivorship of cemented versus cementless TKAs performed using the ROSA\u0026reg; robotic assistance system. This retrospective, single-surgeon, single-center study compares the short-term outcomes and survivorship of cemented and cementless TKAs executed with robotic assistance. We hypothesize that cementless TKAs are not inferior to their cemented counterparts.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003e\u003cem\u003ePatient Selection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis retrospective study analyzed a cohort of patients who underwent cruciate-retaining (CR) total knee arthroplasty (TKA) using either a cementless Persona Trabecular Metal\u0026reg; (TM) prosthesis or a cemented Persona\u0026reg; prosthesis (Zimmer Biomet, Warsaw, IN, USA), all performed with robotic assistance using the ROSA\u0026reg; Knee System (Zimmer Biomet, Warsaw, IN, USA). All procedures were carried out by a single high-volume senior surgeon (F.D.A.) at a single institution between October 2021 and September 2023. Clinical data were extracted from the hospital\u0026rsquo;s information system and stored in a secure, restricted-access database.\u003c/p\u003e\u003cp\u003ePatients were eligible for inclusion if they had a minimum follow-up of one year and had provided written informed consent. Exclusion criteria included concurrent knee surgeries at the time of TKA, bilateral procedures, or refusal to consent.\u003c/p\u003e\u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki and good clinical practice guidelines. The study protocol was approved by the Ethics Committee of Humanitas Research Hospital (protocol code 618/17). Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatients\u0026rsquo; data and PROMs\u003c/em\u003e\u003c/p\u003e\u003cp\u003eData extracted from the institutional database encompassed demographic information, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, surgical procedure duration, length of hospital stay, occurrence of surgical revisions, and any intraoperative, perioperative, or postoperative complications.\u003c/p\u003e\u003cp\u003ePatient reported outcome measures (PROMs) were collected preoperatively and at the final follow-up. These included Western Ontario and McMaster University Osteoarthritis Index (WOMAC) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Knee Society Knee Scoring System [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Oxford Knee Score [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Forgotten Joint-Score 12 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurgical technique\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll patients included in this study underwent primary cruciate-retaining total knee arthroplasty (CR-TKA) performed by a single, highly experienced surgeon (F.D.A.) at a single center. Preoperatively, all patients received intravenous antibiotic prophylaxis consisting of either 2 grams of cefazolin or 600 milligrams of clindamycin. A sterile surgical field was established using disposable drapes, and the ROSA\u0026reg; robotic system was positioned and configured accordingly. A minimally invasive mini-mid vastus medial parapatellar approach was employed for all patients. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eBone resections and ligament balancing were performed according to the ROSA\u0026reg; imageless protocol, following the principles of functional alignment. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Implant selection (cemented vs. cementless) was determined preoperatively based on imaging studies; however, intraoperative assessment of bone quality could lead to a change in the chosen fixation method if suboptimal bone stock was identified.\u003c/p\u003e\u003cp\u003eTo minimize blood loss, 1 gram of tranexamic acid was administered intravenously at the time of incision, followed by an additional 3 grams injected intra-articularly after capsule closure, when deemed clinically appropriate. Skin closure was performed with absorbable subcuticular sutures. No tourniquet was used during any of the procedures\u003c/p\u003e\u003cp\u003e\u003cem\u003ePost-operative management\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFollowing surgery, all patients received a regional analgesic block to facilitate postoperative pain management. A standardized analgesic protocol was implemented to support early mobilization, ideally beginning on the day of surgery. An in-patient physiotherapy program was initiated immediately to improve joint range of motion and muscle strength. Patients also received instruction on the appropriate use of crutches.\u003c/p\u003e\u003cp\u003eWhen clinically appropriate, patients were discharged to continue their rehabilitation at home under the supervision of a licensed physical therapist. Follow-up evaluations were scheduled at 1, 3, 6, and 12 months postoperatively, with annual assessments thereafter. To prevent deep vein thrombosis, low-molecular-weight heparin was prescribed for approximately five weeks.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Analyses\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll statistical analyses were performed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA). For continuous variables, the choice of test depended on the sample size. When the sample size was less than 20, between-group comparisons were conducted using the Two-Sample Wilcoxon Test, while changes from baseline were assessed using the Wilcoxon Signed-Rank Test. For sample sizes greater than or equal to 20, the Independent Samples t-Test was employed for between-group comparisons, and the Paired Samples t-Test was used to evaluate within-group changes from baseline.\u003c/p\u003e\u003cp\u003eFor categorical variables, the statistical method was selected based on the assumptions of the Chi-Square Test. Specifically, this test was applied when at least 80% of the expected cell counts were \u0026ge;\u0026thinsp;5, and no cell had an expected count\u0026thinsp;\u0026lt;\u0026thinsp;1. If these assumptions were violated, the Fisher\u0026rsquo;s Exact Test was used instead\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eBaseline characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe demographic and surgical characteristics of both cohorts are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. A total of 130 cruciate-retaining TKAs were included in the analysis, comprising 80 patients who received the cementless Persona\u0026reg; Trabecular Metal\u0026trade; (TM) implant and 50 patients who received the cemented Persona\u0026reg; implant. Patients in the TM group were significantly younger than those in the cemented group, and the proportion of men patients was significantly higher in the TM group. No other statistically significant demographic differences were observed between the two groups. There were no statistically significant differences between the groups with respect to operative time, number of transfusions, or length of hospital stay\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\u0026nbsp;Demographics\u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCemented\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersona TM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e(years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e74.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e69.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.0018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.5800\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e30.0% (15/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e53.8% (43/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eLikelihood Ratio Chi Square test: P\u0026thinsp;=\u0026thinsp;0.0074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e70.0% (35/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e46.3% (37/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eASA Grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e16.0% (8/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e16.3% (13/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eLikelihood Ratio Chi Square test: P\u0026thinsp;=\u0026thinsp;0.9943\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e76.0% (38/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e76.3% (61/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e8.0% (4/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e7.5% (6/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSurgery Side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e42.0% (21/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e47.5% (38/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eLikelihood Ratio Chi Square test: P\u0026thinsp;=\u0026thinsp;0.5396\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e58.0% (29/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e52.5% (42/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" align=\"left\"\u003e\n \u003cp\u003eSurgical Information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCemented\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersona TM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eOperative Time\u003c/p\u003e\n \u003cp\u003e(skin to skin, minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e86.2\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e82.4\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.2454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eNumber of Transfused Bags\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e100.0% (50/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e98.8% (79/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFisher Exact test: P\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.0% (0/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e1.3% (1/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eLength of Stay\u003c/p\u003e\n \u003cp\u003e(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.2350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\u0026nbsp;Clinical Scores\u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCemented\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersona TM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ebetween groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWOMAC Score (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.0\u003c/p\u003e\n \u003cp\u003e(20.0, 48.0, 80.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (46.3, 54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e\n \u003cp\u003e(14.0, 47.0, 80.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (42.2, 49.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.0985\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e\n \u003cp\u003e(0.0, 11.0, 58.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (10.4, 18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e\n \u003cp\u003e(0.0, 13.0, 50.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (11.1, 16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.8752\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eKSS Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\n \u003cp\u003e(0.0, 7.5, 14.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (5.0, 7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e\n \u003cp\u003e(0.0, 8.0, 17.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (6.6, 8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.0620\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n \u003cp\u003e(4.0, 21.0, 25.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (18.2, 21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e\n \u003cp\u003e(3.0, 21.0, 25.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (18.9, 21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.6387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eKSS Satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\n \u003cp\u003e(0.0, 10.0, 32.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (9.4, 14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\n \u003cp\u003e(0.0, 10.0, 40.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (10.6, 13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.7629\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e\n \u003cp\u003e(0.0, 30.0, 40.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (26.1, 31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\n \u003cp\u003e(0.0, 30.0, 40.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (25.5, 29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.4015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eKSS Expectation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003cp\u003e(8.0, 12.0, 15.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (11.5, 12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\n \u003cp\u003e(6.0, 11.0, 15.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (10.6, 11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.0030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\n \u003cp\u003e(3.0, 9.0, 15.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (9.0, 10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n \u003cp\u003e(6.0, 10.0, 15.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (9.3, 10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Satterthwaite): P\u0026thinsp;=\u0026thinsp;0.8339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eKSS Function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.0\u0026thinsp;\u0026plusmn;\u0026thinsp;17.7\u003c/p\u003e\n \u003cp\u003e(0.0, 53.0, 89.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (50.0, 60.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5\u003c/p\u003e\n \u003cp\u003e(18.0, 55.5, 82.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (50.5, 57.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.7834\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e\n \u003cp\u003e(7.0, 81.0, 100.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (72.2, 81.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5\u003c/p\u003e\n \u003cp\u003e(43.0, 81.0, 100.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (76.8, 82.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Satterthwaite): P\u0026thinsp;=\u0026thinsp;0.3114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOKS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003cp\u003e(10.0, 26.0, 40.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (24.3, 28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\n \u003cp\u003e(10.0, 26.0, 40.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (24.7, 28.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.9715\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\n \u003cp\u003e(22.0, 44.0, 48.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (40.2, 43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\n \u003cp\u003e(24.0, 42.0, 48.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (40.8, 43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.9683\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaired T-Test: P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFJS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78.8\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9\u003c/p\u003e\n \u003cp\u003e(18.8, 82.9, 100.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (73.7, 83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u003c/p\u003e\n \u003cp\u003e(27.1, 83.3, 100.0)\u003c/p\u003e\n \u003cp\u003e95% C.I. (77.2, 84.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.5163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003ePatient-reported outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter a minimum of 1 year of follow-up, statistically significant improvements were observed in all proposed PROMs for both cohorts. However, no significant differences were found between the two groups. These results are showed in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\u0026nbsp;Survival Rate\u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN Revised\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN Cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvival Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAseptic loosening\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCemented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100% [130/130]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersona TM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100% [130/130]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvery cause of revision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCemented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98% [49/50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersona TM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100% [80/80]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eReturn to the operating room\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCemented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98% [49/50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersona TM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.5% [78/80]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\u0026nbsp;Demographics\u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCemented\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersona TM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e(years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e74.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e69.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.0018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.5800\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e30.0% (15/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e53.8% (43/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eLikelihood Ratio Chi Square test: P\u0026thinsp;=\u0026thinsp;0.0074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e70.0% (35/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e46.3% (37/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eASA Grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e16.0% (8/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e16.3% (13/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eLikelihood Ratio Chi Square test: P\u0026thinsp;=\u0026thinsp;0.9943\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e76.0% (38/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e76.3% (61/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e8.0% (4/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e7.5% (6/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSurgery Side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e42.0% (21/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e47.5% (38/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eLikelihood Ratio Chi Square test: P\u0026thinsp;=\u0026thinsp;0.5396\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e58.0% (29/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e52.5% (42/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" align=\"left\"\u003e\n \u003cp\u003eSurgical Information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCemented\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersona TM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eOperative Time\u003c/p\u003e\n \u003cp\u003e(skin to skin, minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e86.2\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e82.4\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.2454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eNumber of Transfused Bags\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e100.0% (50/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e98.8% (79/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFisher Exact test: P\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.0% (0/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e1.3% (1/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eLength of Stay\u003c/p\u003e\n \u003cp\u003e(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT-test (Pooled): P\u0026thinsp;=\u0026thinsp;0.2350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eSurvivorship and Complications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 130 TKAs included in this study, one patient in the cemented cohort required revision surgery due to postoperative stiffness and pain, which occurred six months after the index procedure. The revision involved patellar resurfacing and polyethylene insert exchange, resulting in pain resolution and restoration of full range of motion.\u003c/p\u003e\n\u003cp\u003eIn the cementless cohort, two patients developed postoperative stiffness and subsequently underwent manipulation under anesthesia (MUA) at five and three months postoperatively, respectively. Both cases resulted in successful recovery of full range of motion. Implant survival rates are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eOne patient in the cemented group experienced significant intraoperative blood loss and required postoperative transfusion of four units of packed red blood cells. No other patients in either cohort required transfusion.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this retrospective study comparing cemented and cementless cruciate-retaining total knee arthroplasties (CR-TKAs) performed with robotic assistance using the ROSA\u0026reg; Knee System, no statistically significant differences were observed in patient-reported outcome measures (PROMs) or short-term implant survivorship between the two groups. Both cohorts demonstrated significant postoperative improvements across all PROMs, with comparable rates of complications and returns to the operating room.\u003c/p\u003e\u003cp\u003eThe cementless cohort, which primarily consisted of younger men patients, experienced no revisions during the follow-up period, whereas one revision was recorded in the cemented group. These findings support the clinical viability of cementless implants in appropriately selected patients and underscore the potential value of robotic assistance in enhancing surgical accuracy, particularly in cementless fixation, where precision is critical for successful osseointegration.\u003c/p\u003e\u003cp\u003eAlthough the clinical outcomes of cementless implants were considered suboptimal in earlier generations [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], advancements in biomaterials and implant design have endowed the current generation with promising potential for long-term durability and performance.[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWhile cemented fixation remains the most commonly used technique in total knee arthroplasty (TKA), the adoption of cementless fixation has steadily increased, now accounting for over 20% of all procedures. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis shift is largely driven by the rising demand for TKA, which has led to a broader patient demographic, including a growing proportion of younger and more physically active individuals.[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eCementless fixation is often preferred in younger patients due to the presence of a direct bone\u0026ndash;implant interface, which may offer more durable and long-lasting fixation compared to cemented implants. This approach reduces the risk of loosening secondary to osteolysis or third-body wear associated with cement debris and may facilitate easier revision surgery by minimizing bone loss.[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAs reflected in the demographic findings of our cohort, cementless prostheses are primarily utilized in younger patients and mens. Currently, survivorship data for cementless implants in femen patients over the age of 65 remain inconclusive, leading many surgeons to refrain from recommending this fixation method in this population. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this is the first study to evaluate the clinical outcomes of the ROSA\u0026reg; Knee System robotic technology in a cohort including both cemented and cementless total knee arthroplasties.\u003c/p\u003e\u003cp\u003ePrecise bone cutting is critical to reducing the risk of failure in cementless prosthesis implantation. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] Therefore, the use of robotic technology, which significantly enhances the accuracy of cuts [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], compared to traditional techniques, could be beneficial for the cementless prosthesis.\u003c/p\u003e\u003cp\u003eOur results demonstrate significant improvements in patient-reported outcome measures (PROMs) from the preoperative to postoperative period in both groups, with no statistically significant differences observed between the cemented and cementless cohorts. These findings suggest that, in the short term, both implant types yield comparable clinical outcomes. Moreover, our results are consistent with previously published studies comparing cemented and cementless total knee arthroplasties performed with robotic assistance. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn the study by Molho et al., 335 cementless implants were compared with 247 cemented implants, demonstrating comparable short-term patient-reported outcome measures (PROMs), but a significantly higher rate of return to the operating room in the cemented group. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] In our study, the rate of return to the operating room did not reach statistical significance.\u003c/p\u003e\u003cp\u003eSimilarly, the results of McCormick et al. demonstrated equivalent PROMs in the short term between the cemented and cementless cohort. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eGiven the comparable outcomes observed between the two implant types, we believe that selecting cementless implants for appropriately indicated patients is critical to improving long-term implant survivorship and reducing the risk of aseptic loosening. Furthermore, the potential time and cost savings associated with cementless techniques may offer additional advantages, particularly in high-volume surgical settings. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] can make them a more economical alternative.\u003c/p\u003e\u003cp\u003eAlthough the TM group demonstrated a shorter mean operative time in our study, the difference was not statistically significant. We hypothesize that this result may be influenced by the relatively small sample size and the learning curve associated with the adoption of robotic-assisted surgery in our institution, which began in 2020.\u003c/p\u003e\u003cp\u003eGiven the short-term nature of this study, substantial differences in implant survivorship between the two cohorts were not anticipated. Consistent with this expectation, we observed only three returns to the operating room and a single revision procedure. One patient in the cemented group required revision surgery due to persistent pain and stiffness, which was managed with polyethylene insert exchange and patellar resurfacing. The other two returns to the operating room involved cases of stiffness in the cementless group; both were successfully treated with manipulation under anesthesia (MUA), resulting in improved range of motion.\u003c/p\u003e\u003cp\u003eThese findings are highly consistent with existing literature on both robotically assisted and conventionally performed total knee arthroplasty procedures. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral limitations inherent to this study should be acknowledged. First, the procedures were performed by a single surgeon at a single institution, which may limit the generalizability of the findings to broader clinical practice. Second, the retrospective study design introduces inherent methodological limitations, including potential selection bias. The method of fixation was not randomly assigned, thereby precluding definitive conclusions regarding the universal applicability of cementless fixation in TKA patients.\u003c/p\u003e\u003cp\u003eMoreover, the relatively short duration of follow-up may not fully capture long-term differences in outcomes between the two groups. Ongoing surveillance and future prospective, randomized studies with longer follow-up are warranted to better define optimal patient selection criteria and to evaluate the long-term performance of cemented versus cementless fixation methods.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis short-term comparison of cruciate-retaining total knee arthroplasty (CR-TKA) using cemented Persona\u0026reg; and cementless Persona\u0026reg; Trabecular Metal\u0026trade; implants, both performed with robotic assistance, revealed no statistically significant differences in patient-reported outcome measures (PROMs) or implant survivorship. In appropriately selected patients, cementless fixation may represent a viable alternative, potentially reducing the risk of aseptic loosening and lowering long-term healthcare costs. The adoption of robotic systems may provide a distinct advantage in achieving optimal surgical precision, particularly in cementless procedures where accurate component alignment is critical for long-term success.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding statement\u003c/h2\u003e\u003cp\u003eThe author declares that no funding was received or utilized for the preparation, research, or writing of this paper.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conceptualization; methodology, U.V.; validation: F.D.A. and M.L.; formal analysis and investigation, U.V., F.D.D., M.A., and L.R.; writing\u0026mdash;original draft preparation, U.V.; writing\u0026mdash;review and editing, F.D.A. and M.L.; supervision, F.D.A. and M.L. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data can be found in the following online database: Zenodo DOI: 10.5281/zenodo.15755384\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKurtz S, Ong K, Lau E, Mowat F, Halpern eM (2007) \u0026laquo;Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030\u0026raquo;, \u003cem\u003eJ. Bone Joint Surg. 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Robotic assistance may improve the accuracy of cementless implantation and promote favorable outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA retrospective review was conducted of 130 cruciate-retaining primary TKAs performed using the ROSA\u0026reg; robotic-assisted system between October 2021 and September 2023 by a single high-volume surgeon. Patients received either a cementless Persona Trabecular Metal\u0026reg; (n\u0026thinsp;=\u0026thinsp;80) or cemented Persona\u0026reg; (n\u0026thinsp;=\u0026thinsp;50) prosthesis. Patient demographics, perioperative data, complications, and revisions were recorded. Patient-reported outcome measures (PROMs) WOMAC, Oxford Knee Score, Knee Society Score, and Forgotten Joint Score-12 were collected preoperatively and at minimum one-year follow-up.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients in the cementless group were younger (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and more frequently men (p\u0026thinsp;=\u0026thinsp;0.003). Both groups showed significant improvement in all PROMs from baseline (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with no statistically significant differences in final PROMs between groups. One revision occurred in the cemented group (2.0%) due to stiffness and pain; two manipulations under anesthesia (MUA) were required in the cementless group (2.5%). No differences were observed in operative time or hospital length of stay.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAt short-term follow-up, cementless and cemented robotic-assisted TKAs demonstrated equivalent improvements in PROMs and survivorship. Cementless implants may represent a viable option in appropriately selected patients, particularly younger individuals, when combined with robotic precision. Long-term data are needed to confirm durability.\u003c/p\u003e","manuscriptTitle":"Similar clinical and survival outcomes between robotic-assisted cemented and cementless total knee arthroplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 10:38:54","doi":"10.21203/rs.3.rs-7124562/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-01T14:46:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T06:44:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170221442762473119646082152478926695135","date":"2025-08-06T20:35:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-25T09:03:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-17T11:33:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T11:32:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-07-14T21:44:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"94cfc22e-c8a8-4bdc-857c-ec4f633c75be","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:44:42+00:00","versionOfRecord":{"articleIdentity":"rs-7124562","link":"https://doi.org/10.1007/s00402-025-06100-7","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2025-10-24 16:17:08","publishedOnDateReadable":"October 24th, 2025"},"versionCreatedAt":"2025-07-29 10:38:54","video":"","vorDoi":"10.1007/s00402-025-06100-7","vorDoiUrl":"https://doi.org/10.1007/s00402-025-06100-7","workflowStages":[]},"version":"v1","identity":"rs-7124562","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7124562","identity":"rs-7124562","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}