Systematic review on comparative outcomes in cell-based regeneration techniques vs. traditional techniques in osseointegration of implants in total knee arthroplasty

Document Type : Review


Department of Orthopaedics, Dr. Panjabrao Deshmukh Memorial Medical College and Hospital, Amravati, Maharashtra, India


Background: Total Knee Arthroplasty (TKA), a proven and cost-effective orthopedic surgical technique, consistently reduces preoperative morbidity, enhances functional capacity, and alleviates pain in degenerative knee osteoarthritis.
Objectives: The aim of this study was to compare cell-based and traditional techniques in Osseointegration in Total Knee Arthroplasty.
Methods: The literature search was conducted, across various electronic databases including Google Scholar, PubMed, Web of Science, Scopus, and the Cochrane Library. The search was conducted from 2001 to 2022, aiming to identify studies related to TKA and the various techniques employed in the procedure. Articles were screened based on the relevance to cell-based and traditional Osseointegration techniques, focusing on extracting information related to outcomes and complications.
Results: We included 11 studies in the study, employing the Cochrane 'Risk of Bias tool' to assess bias in randomized trials across five domains. The majority of articles demonstrated low risk (56.36%), signifying reliability, while 'Unclear' studies (32.73%) had some ambiguity without invalidating results. Studies classified as 'High risk' (10.91%) indicated substantial bias and potential errors. Our findings suggest that cell-based techniques are efficient for the treatment of TKA.
Conclusion: Osseointegration presents significant advantages in terms of function and pain relief for patients willing to accept associated risks. Cell-based techniques have proven effective in preventing the need for revision in TKA, demonstrating long-term effects.


  1. Lewallen EA, Riester SM, Bonin CA, Kremers HM, DudakovicA, Kakar S, et al. Biological strategies for improved osseointegration and osteoinduction of porous metal orthopedic implants. Tissue Eng Part B Rev. 2015;21(2):218-30. doi:10.1089/ten.teb.2014.0333 PMid:25348836 PMCid:PMC4390115
  2. Vaidya SV, Jogani AD, Pachore JA, Armstrong R, Vaidya CS. India Joining the World of Hip and Knee Registries: Present Status-A Leap Forward. Indian J Orthop. 2020;55(Suppl 1):46-55. doi:10.1007/s43465-020-00251-y PMid:34122754 PMCid:PMC8149501
  3. Accessed 4 June 2020
  4. Feng JE, Novikov D, Anoushiravani AA, Schwarzkopf R. Total knee arthroplasty: improving outcomes with a multidisciplinary approach. J Multidiscip Healthc. 2018;11:63-73. doi:10.2147/JMDH.S140550 PMid:29416347 PMCid:PMC5790068
  5. Liu M-M, Tian M, Luo C, Wang S, Shao L. Continuous cryotherapy vs. traditional cryotherapy after total knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Front Surg. 2023;9:1073288. doi:10.3389/fsurg.2022.1073288 PMid:36713652 PMCid:PMC9874230
  6. Mulcahy H, Chew FS. Current concepts in knee replacement: complications. Am J Roentgenol. 2014;202(1):W76-86. doi:10.2214/AJR.13.11308 PMid:24370168
  7. Liu Y, Rath B, Tingart M, Eschweiler J. Role of implants surface modification in osseointegration: A systematic review. J Biomed Mater Res A. 2020;108(3):470-484. doi:10.1002/jbm.a.36829 PMid:31664764
  8. Angele P, Docheva D, Pattappa G, Zellner J. Cell-based treatment options facilitate regeneration of cartilage, ligaments and meniscus in demanding conditions of the knee by a whole joint approach. Knee Surg Sports Traumatol Arthrosc 2022;30:1138-1150 doi:10.1007/s00167-021-06497-9 PMid:33666685 PMCid:PMC9007795
  9. MusiaƂ-Wysocka A, Kot M, Majka M. The Pros and Cons of Mesenchymal Stem Cell-Based Therapies. Cell Transplant. 2019; 28(7):801-812. doi:10.1177/0963689719837897 PMCid:PMC6719501
  10. Freitag J, Bates D, Boyd R, Shah K, Barnard A, Huguenin L, Tenen A. Mesenchymal stem cell therapy in the treatment of osteoarthritis: reparative pathways, safety and efficacy- a review. BMC Musculoskelet Disord. 2016;17:230. doi:10.1186/s12891-016-1085-9 PMid:27229856 PMCid:PMC4880954
  11. Zellner J, Krutsch W, Pfeifer C, Koch M, Nerlich M, Angele P. Autologous chondrocyte implantation for cartilage repair: current perspectives. Orthop Res Rev. 2015;7:149-158 doi:10.2147/ORR.S65569
  12. Inderhaug E, Solheim E. OsteochondralAutograft Transplant (Mosaicplasty) for Knee Articular Cartilage Defects. Essent Surg Tech. 2019;9(4):e34.1-2. doi:10.2106/JBJS.ST.18.00113 PMid:32051778 PMCid:PMC6974309
  13. Gomoll AH, Minas T. Debridement, Microfracture, and OsteochondralAutograft Transfer for Treatment of Cartilage Defects. Saunders B. 2011:48-53. doi:10.1016/B978-1-4160-6654-5.00005-5
  14. Lopa S, Colombini A, Moretti M, de Girolamo L. Injective mesenchymal stem cell-based treatments for knee osteoarthritis: from mechanisms of action to current clinical evidences. Knee Surg Sports Traumatol Arthrosc. 2019;27(6):2003-2020. doi:10.1007/s00167-018-5118-9 PMid:30159741 PMCid:PMC6541568
  15. Yamagata K, Nakayamada S, Tanaka Y. Use of mesenchymal stem cells seeded on the scaffold in articular cartilage repair. Inflamm Regen. 2018;38:4. doi:10.1186/s41232-018-0061-1 PMid:29560045 PMCid:PMC5846298
  16. Unune D, Brown G, Reilly G. Thermal based surface modification techniques for enhancing the corrosion and wear resistance of metallic implants: A review. Vacuum 2022;(203).11129 doi:10.1016/j.vacuum.2022.111298
  17. Ayatollahi MR, Davari MH, Shirazi HA, Asnafi A. To Improve Total Knee Prostheses Performance Using Three-phase Ceramic-based Functionally Graded Biomaterial. Front Mater. 2019;6(17) doi:10.3389/fmats.2019.00107
  18. Mishra S, Chowdhary R. PEEK materials as an alternative to titanium in dental implants: A systematic review. Clin Implant Dent Relat Res. 2019;21(1):208-222. doi:10.1111/cid.12706
  19. Lei PF, Hu RY, Hu YH. Bone Defects in Revision Total Knee Arthroplasty and Management. Orthop Surg. 2019;11(1):15-24. doi:10.1111/os.12425 PMid:30809942 PMCid:PMC6430493
  20. Schmidt AH. Autologous bone graft: Is it still the gold standard? Injury. 2021;52 Suppl 2:S18-S22. doi:10.1016/j.injury.2021.01.043 PMid:33563416
  21. Shafaghi R, Rodriguez O, Schemitsch EH, Zalzal P, Waldman SD, Papini M, et al. A review of materials for managing bone loss in revision total knee arthroplasty. Mater Sci Eng C Mater Biol Appl. 2019; 104:109941. doi:10.1016/j.msec.2019.109941
  22. Marlovits S, Hombauer M, Truppe M. Changes in the ratio of type-I and type-II collagen expression during monolayer culture of human chondrocytes. J Bone Joint Surg Br. 2004;86:286-95. doi:10.1302/0301-620X.86B2.14918
  23. Centeno CJ, Busse D, Kisiday J, Keohan C, Freeman M, Karli D. Increased knee cartilage volume in degenerative joint disease using percutaneously implanted, autologous mesenchymal stem cells. Pain Physician 2008;11(3):343-53. doi:10.36076/ppj.2008/11/343 PMid:18523506
  24. Centeno CJ, Busse D, Kisiday J, Keohan C, Freeman M, Karli D. Regeneration of meniscus cartilage in a knee treated with percutaneously implanted autologous mesenchymal stem cells. Med Hypotheses 2008;71(6):900-8. doi:10.1016/j.mehy.2008.06.042 PMid:18786777
  25. Oztürk A, Ozdemir MR, Ozkan Y. Osteochondralautografting (mosaicplasty) in grade IV cartilage defects in the knee joint: 2- to 7-year results. Int Orthop. 2006;30(3):200-4. doi:10.1007/s00264-005-0068-5 PMid:16523335 PMCid:PMC2532091
  26. Chavda, S. Levin L. Human studies of vertical and horizontal alveolar ridge augmentation comparing different types of bone graft materials: A systematic review. J Oral Implantol. 2018; 44: 74-84. doi:10.1563/aaid-joi-D-17-00053 PMid:29135351
  27. Brod B, Patel T, Hargett R, Lebrun B, Ahmed S, Branly R, et al. Hypoxic brain trauma causing blindness in a multiple gunshot wound patient: a challenging clinical scenario with a brief review of the literature. Novel Clin Med. 2024; 3(1): 50-57. doi: 10.22034/ncm.2023.408036.1102
  28. Chabord P. Bone marrow mesenchymal stem cells: Historical overview and concepts. Hum Gene Ther. 2010;21:1045-1056. doi:10.1089/hum.2010.115 PMCid:PMC4823383
  29. Kahn TL, Soheili A, Schwarzkopf R. Outcomes of total knee arthroplasty in relation to preoperative patient-reported and radiographic measures: data from the osteoarthritis initiative. Geriatr Orthop Surg Rehabil. 2013;4(4):117-26. doi:10.1177/2151458514520634 PMid:24600532 PMCid:PMC3943364
  30. Aschoff HH, Kennon RE, Keggi JM, Rubin LE. Transcutaneous, distal femoral, intramedullary attachment for above-the-knee prostheses: an endo-exo device. J Bone Joint Surg Am. 2010; 92 (Suppl 2):180-6 doi:10.2106/JBJS.J.00806 PMid:21123601
  31. DiBartola AC, Wright BM, Magnussen RA, Flanigan DC. Clinical outcomes after autologous chondrocyte implantation in adolescents' knees: a systematic review. Arthroscopy. 2016. doi:10.1016/j.arthro.2016.03.007
  32. Fortier LA, Cole BJ, McIlwraith CW. Science and animal models of marrow stimulation for cartilage repair.J Knee Surg.2012: 25:3-8. doi:10.1055/s-0032-1310389 PMid:22624241
  33. Franke KF, Nusem I, Gamboa G, Morgan DA. Outcome of revision total knee arthroplasty with bone allograft in 30 cases. Acta Orthop Belg. 2013; 79: 427-434. 46
  34. Baldwin P, Li DJ, Auston DA, Mir HS, Yoon RS, Koval KJ. Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence and Indications for Use in the Setting of Orthopaedic Trauma Surgery. J Orthop Trauma. 2019;33(4):203-213. doi:10.1097/BOT.0000000000001420 PMid:30633080
  35. Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee arthroplasty compared to healthy adults. J Orthop Sports Phys Ther. 2010;40(9):559-67. doi:10.2519/jospt.2010.3317 PMid:20710093 PMCid:PMC3164265