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Figure 1
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Figure 2
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Study flow diagram.
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Figure 3

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 4

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 5

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Cemented versus uncemented with HA, Outcome 1 Absolute rotation about transverse axis in degrees (60 months).
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Analysis 1.1

Comparison 1 Cemented versus uncemented with HA, Outcome 1 Absolute rotation about transverse axis in degrees (60 months).

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Comparison 1 Cemented versus uncemented with HA, Outcome 2 Absolute rotation about longitudinal axis in degrees (60 months).
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Analysis 1.2

Comparison 1 Cemented versus uncemented with HA, Outcome 2 Absolute rotation about longitudinal axis in degrees (60 months).

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Comparison 1 Cemented versus uncemented with HA, Outcome 3 Absolute rotation about sagittal axis in degrees (60 months).
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Analysis 1.3

Comparison 1 Cemented versus uncemented with HA, Outcome 3 Absolute rotation about sagittal axis in degrees (60 months).

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Comparison 1 Cemented versus uncemented with HA, Outcome 4 Arthroplasty instability (arthroplasty instability was considered an event).
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Analysis 1.4

Comparison 1 Cemented versus uncemented with HA, Outcome 4 Arthroplasty instability (arthroplasty instability was considered an event).

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Comparison 2 Cemented versus uncemented with and without HA, Outcome 1 Absolute rotation about transverse axis in degrees (60 months).
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Analysis 2.1

Comparison 2 Cemented versus uncemented with and without HA, Outcome 1 Absolute rotation about transverse axis in degrees (60 months).

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Comparison 2 Cemented versus uncemented with and without HA, Outcome 2 Absolute rotation about longitudinal axis in degrees (60 months).
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Analysis 2.2

Comparison 2 Cemented versus uncemented with and without HA, Outcome 2 Absolute rotation about longitudinal axis in degrees (60 months).

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Comparison 2 Cemented versus uncemented with and without HA, Outcome 3 Absolute rotation about sagittal axis in degrees (60 months).
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Analysis 2.3

Comparison 2 Cemented versus uncemented with and without HA, Outcome 3 Absolute rotation about sagittal axis in degrees (60 months).

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Comparison 2 Cemented versus uncemented with and without HA, Outcome 4 Maximum total point motion in millimeters (12 months).
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Analysis 2.4

Comparison 2 Cemented versus uncemented with and without HA, Outcome 4 Maximum total point motion in millimeters (12 months).

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Comparison 2 Cemented versus uncemented with and without HA, Outcome 5 Maximum total point motion in millimeters (24 months).
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Analysis 2.5

Comparison 2 Cemented versus uncemented with and without HA, Outcome 5 Maximum total point motion in millimeters (24 months).

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Comparison 2 Cemented versus uncemented with and without HA, Outcome 6 Arthroplasty instability (arthroplasty instability was considered an event).
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Analysis 2.6

Comparison 2 Cemented versus uncemented with and without HA, Outcome 6 Arthroplasty instability (arthroplasty instability was considered an event).

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Comparison 3 Cemented versus uncemented without HA, Outcome 1 Maximum total point motion in millimeters (12 months).
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Analysis 3.1

Comparison 3 Cemented versus uncemented without HA, Outcome 1 Maximum total point motion in millimeters (12 months).

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Comparison 3 Cemented versus uncemented without HA, Outcome 2 Maximum total point motion in millimeters (24 months).
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Analysis 3.2

Comparison 3 Cemented versus uncemented without HA, Outcome 2 Maximum total point motion in millimeters (24 months).

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Comparison 3 Cemented versus uncemented without HA, Outcome 3 Arthroplasty instability (arthroplasty instability was considered an event).
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Analysis 3.3

Comparison 3 Cemented versus uncemented without HA, Outcome 3 Arthroplasty instability (arthroplasty instability was considered an event).

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Summary of findings for the main comparison. Uncemented fixation with and without hydroxyapatite compared to cemented fixation for osteoarthritis and other non‐traumatic diseases

Uncemented fixation with and without hydroxyapatite compared to cemented fixation for osteoarthritis and other non‐traumatic diseases

Patient or population: Patients with osteoarthritis and other non‐traumatic diseases
Settings: Osteoarthritis (non‐post‐traumatic patients)
Intervention: Uncemented with and without hydroxyapatite
Comparison: Cemented

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Cemented

Uncemented with and without hydroxyapatite

Arthroplasty instability ‐

inferred from roentgen stereophotogrammetric analysis

(Available data analysis)

Follow‐up: 1 to 2 years

287 per 1000

135 per 1000
(69 to 264)

RR 0.47
(0.24 to 0.92)

216
(3 studies)

⊕⊕⊕
moderate1

Arthroplasty instability was considered an event. This outcome predicts knee arthroplasty revision rates because of aseptic loosening (provides indirect evidence).

Absolute risk difference = 16% (95% CI ‐0.27 to ‐0.05)

Relative percent change = 53% (95% CI 8 to 76%)

NNTH = 7 (95% CI 5 to 44)

Survival rate of the implant (any change of a component)

See comment

See comment

0
(0)

See comment

Survival rate of the implant is a long term outcome not available in included studies (2 to 5 year follow‐up).

Global Assessment (Patient)

See comment

See comment

27
(1)

See comment

Toksvig‐Larsen 1988 reported that all of the patients were satisfied with the results at a 2 year follow‐up. We found no mention of degrees of satisfaction.

Functional measures with validated instruments

See comment

See comment

240
(4)

See comment

Knee Society and HSS knee scores were recorded. The SD of the mean of the results was not reported. The authors found no significant difference between the groups.

Pain

See comment

See comment

0
(0)

See comment

Not reported.

Health‐related quality of life measures

See comment

See comment

0
(0)

See comment

Not reported.

Total adverse event

See comment

See comment

0
(0)

See comment

No evidence available2

*The basis for the assumed risk (e.g. the median control group risk among studies) is provided in the footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Roentgen stereophotogrammetric analysis predicts the arthroplasty instability. We downgraded for indirectness of evidence.

2The type of fixation of the femoral component was different from the tibial component in 3 out of 4 studies. It was not possible to correlate some adverse events to the cementation of the arthroplasty from the study description even when the type of fixation of the femoral and tibial components was the same (Nilsson 1999).

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Summary of findings for the main comparison. Uncemented fixation with and without hydroxyapatite compared to cemented fixation for osteoarthritis and other non‐traumatic diseases
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Table 1. Complications

Complications

Toksvig‐Larsen 1998

Nilsson 1999

Carlsson 2005

Uvehammer 2007

Unrelated deaths

(N and fixation)

2 cemented

3 cemented, 5 uncemented with hydroxyapatite

1 cemented, 4 uncemented without hydroxyapatite,

1 uncemented with hydroxyapatite

2 cemented, 1 uncemented with hydroxyapatite

Cardiac infarction

(N and fixation)

1 cemented

1?

(5‐day PO)

‐

‐

Revision because of loosening

(N and fixation)

‐

1 uncemented with hydroxyapatite

‐

‐

Revision because of infection

(N and fixation)

‐

2 uncemented with hydroxyapatite

1 uncemented without hydroxyapatite

‐

Revision because of instability

(N and fixation)

‐

‐

1 cemented

‐

Cerebral hemorrhage

(N and fixation)

‐

1 ?

‐

‐

Cerebral infarction

(N and fixation)

‐

1 cemented (2‐year PO)

‐

‐

Periprosthetic fractures

(N and fixation)

‐

2 cemented, 1 uncemented with hydroxyapatite

‐

‐

Aseptic necrosis of the patella

(N and fixation)

‐

1?

‐

‐

? = Type of fixation not described

PO = postoperative

N = number of participants
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Table 1. Complications
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Comparison 1. Cemented versus uncemented with HA

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Absolute rotation about transverse axis in degrees (60 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Intention‐to‐treat analysis

2

160

Mean Difference (IV, Random, 95% CI)

0.17 [‐0.12, 0.45]

1.2 Available data analysis

2

134

Mean Difference (IV, Random, 95% CI)

0.19 [‐0.09, 0.47]

2 Absolute rotation about longitudinal axis in degrees (60 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Intention‐to‐treat analysis

2

160

Mean Difference (IV, Random, 95% CI)

0.26 [0.04, 0.47]

2.2 Available data analysis

2

134

Mean Difference (IV, Random, 95% CI)

0.17 [‐0.12, 0.46]

3 Absolute rotation about sagittal axis in degrees (60 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 Intention‐to‐treat analysis

2

160

Mean Difference (IV, Random, 95% CI)

0.22 [0.01, 0.42]

3.2 Available data analysis

2

134

Mean Difference (IV, Random, 95% CI)

0.14 [‐0.02, 0.31]

4 Arthroplasty instability (arthroplasty instability was considered an event) Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

4.1 Intention‐to‐treat analysis (missing participants were categorized unstable)

2

160

Risk Ratio (M‐H, Random, 95% CI)

0.47 [0.26, 0.85]

4.2 Intention‐to‐treat analysis (missing participants were categorized stable)

2

160

Risk Ratio (M‐H, Random, 95% CI)

0.34 [0.15, 0.75]

4.3 Available data analysis (arthroplasty instability was considered an event)

2

149

Risk Ratio (M‐H, Random, 95% CI)

0.34 [0.15, 0.74]
Figuras y tablas -
Comparison 1. Cemented versus uncemented with HA
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Comparison 2. Cemented versus uncemented with and without HA

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Absolute rotation about transverse axis in degrees (60 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Intention‐to‐treat analysis

2

210

Mean Difference (IV, Random, 95% CI)

0.15 [‐0.08, 0.39]

1.2 Available data analysis

2

179

Mean Difference (IV, Random, 95% CI)

0.19 [‐0.03, 0.41]

2 Absolute rotation about longitudinal axis in degrees (60 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Intention‐to‐treat analysis

2

210

Mean Difference (IV, Random, 95% CI)

0.33 [0.09, 0.58]

2.2 Available data analysis

2

179

Mean Difference (IV, Random, 95% CI)

0.25 [‐0.14, 0.64]

3 Absolute rotation about sagittal axis in degrees (60 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 Intention‐to‐treat analysis

2

210

Mean Difference (IV, Random, 95% CI)

0.20 [0.04, 0.36]

3.2 Available data analysis

2

179

Mean Difference (IV, Random, 95% CI)

0.15 [0.01, 0.29]

4 Maximum total point motion in millimeters (12 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

4.1 Intention‐to‐treat analysis

2

176

Mean Difference (IV, Random, 95% CI)

0.60 [0.38, 0.82]

4.2 Available data analysis

2

168

Mean Difference (IV, Random, 95% CI)

0.61 [0.37, 0.84]

5 Maximum total point motion in millimeters (24 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

5.1 Intention‐to‐treat analysis

2

173

Mean Difference (IV, Random, 95% CI)

0.52 [0.31, 0.72]

5.2 Available data analysis

2

167

Mean Difference (IV, Random, 95% CI)

0.52 [0.31, 0.74]

6 Arthroplasty instability (arthroplasty instability was considered an event) Show forest plot

3

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

6.1 Intention‐to‐treat analysis (missing participants were categorized unstable)

3

238

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.36, 1.68]

6.2 Intention‐to‐treat analysis (missing participants were categorized stable)

3

238

Risk Ratio (M‐H, Random, 95% CI)

0.40 [0.22, 0.73]

6.3 Available data analysis (arthroplasty instability was considered an event)

3

216

Risk Ratio (M‐H, Random, 95% CI)

0.47 [0.24, 0.92]
Figuras y tablas -
Comparison 2. Cemented versus uncemented with and without HA
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Comparison 3. Cemented versus uncemented without HA

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Maximum total point motion in millimeters (12 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Intention‐to‐treat analysis

2

126

Mean Difference (IV, Random, 95% CI)

0.62 [0.42, 0.81]

1.2 Available data analysis

2

119

Mean Difference (IV, Random, 95% CI)

0.64 [0.43, 0.85]

2 Maximum total point motion in millimeters (24 months) Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Intention‐to‐treat analysis

2

123

Mean Difference (IV, Random, 95% CI)

0.52 [0.33, 0.72]

2.2 Available data analysis

2

117

Mean Difference (IV, Random, 95% CI)

0.54 [0.33, 0.75]

3 Arthroplasty instability (arthroplasty instability was considered an event) Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

3.1 Intention‐to‐treat analysis (missing participants were categorized unstable)

2

128

Risk Ratio (M‐H, Random, 95% CI)

0.66 [0.37, 1.17]

3.2 Intention‐to‐treat analysis (missing participants were categorized stable)

2

128

Risk Ratio (M‐H, Random, 95% CI)

0.61 [0.20, 1.90]

3.3 Available data analysis

2

116

Risk Ratio (M‐H, Random, 95% CI)

0.54 [0.24, 1.22]
Figuras y tablas -
Comparison 3. Cemented versus uncemented without HA
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