The demographics of total knee arthroplasty (TKA) patients are changing. Individuals are more active, younger, and more obese. These changing demographics and a higher demand for longevity creates a new challenge for reliable and long-term implant fixation. Historically, cemented fixation has remained the gold standard, as cementless design and techniques from the 1980s and 1990s did not obtain long-term positive outcomes due to a failure of ingrowth onto the implants. Advances in the modern-day cementless TKA designs appear to have overcome their initial challenges, indicating the dependence of cementless TKA on implant design. However, there remains the perception that cementless total knee arthroplasty are inferior to cemented TKA. This review discusses the longer-term survivorship data for recent systems, which has shown the potential advantages of cementless fixation.