Cement Fixation Research Articles

Screw and cement fixation of large defects in total knee arthroplasty: A sequel

A further follow-up study of the 57 patients with tibial defects filled with cement and screws during total knee arthroplasty, which was presented in The Journal of Arthroplasty in 1986, continues to show no signs of failure of the cement, radiolucency at the bone-cement interface, or loosening of the prosthesis.

Ｈａｒｒｉｓ‐Ｇａｌａｎｔｅ Ｐｏｒｏｕｓ Ｂｉｐｏｌａｒ Ｈｉｐ Ｐｒｏｓｔｈｅｓｉｓ ｓｔｅｍ側の変化について

We have applied 15 Harris-Galante cementless porous-coated prostheses in 14 patients, comprising cases of intracapsular fracture, osteoarthritis, rheumatoid-arthritis, and femomal head necrosis. The patients were separated radiographically two groups based on the preoperative Singh index.Postoperatively JOA scores were compared between the two groups.Three patients were male, and 11 were female. The mean age at operation was 64.9 years (42-89 years). The mean followup period was 46.7 months (range: 27-74 months). The average post Sigificant correlation between preoperative Singh index and postoperative JOA score was observed. The average postoperative JOA score in the severe porosis group was 73.3 points (67-80); in the non porosis group the average post-opratve JOA score was 91.4 points (84-100). A radiolucent zone tended to appear more frequently and was assouafed with aggrawaton of severe conditions in the porosis group.Based on the results, we recommend the use of the cementless porous stem in patients without osteoporosis. Cement fixation sheuld be used in patients with severe porosis.

リウマチ膝に対するセメント非使用人工関節置換術の経験

The results of fourteen press-fit (uncemented) Kinemax total knee arthroplasties (TKAs) were analyzed and compared to twelve cemented Kinemax TKAs. Uncemented TKAs were used for rheumatoid patients with or without diabetes who had rather good bone quality. The mean post-oprative JOA-RA knee scores at an average of 8.4 months after operation were 65.4 for uncemented knees compared to 62.4 for cemented knees. The difference was not statistically significant. There were a few complications: two tibial component subsidences in uncemented knees and a patellar fracture in a cemented knee. Cement fixation of Kinemax appears to provide satisfactory results in some osteoporotic cases.

Orthopedic prosthesis fixation.

The fixation of orthopedic implants has been one of the most difficult and challenging problems. The fixation can be achieved via: (a) direct mechanical fixation using screws, pins, wires, etc.; (b) passive or interference mechanical fixation where the implants are allowed to move or merely positioned onto the tissue surfaces; (c) bone cement fixation which is actually a grouting material; (d) biological fixation by allowing tissues to grow into the interstices of pores or textured surfaces of implants; (e) direct chemical bonding between implant and tissues; or (f) any combination of the above techniques. This article is concerned with various fixation techniques including the potential use of electrical, pulsed electromagnetic field, chemical stimulation using calcium phosphates for the enhancement of tissue ingrowth, direct bonding with bone by glass-ceramics and resorbable particle impregnated bone cement to take advantages of both the immediate fixation offered by the bone cement and long term fixation due to tissue ingrowth.

Alumina Versus Polyethylene in Total Knee Arthroplasty

The cementless alumina total knee prosthesis, which uses alumina in the portions coming in contact with the bone and a combination of alumina and ultra-high molecular-weight polyethylene (UHMWPE) in the sliding portions, is referred to as a total condylar. Alumina total knee arthroplasty was performed on 137 patients, including 103 rheumatoid arthritis (RA) and 34 osteoarthrosis (OA) patients, from January 1982 to February 1985. The follow-up period was seven years 11 months and four years ten months, respectively. At follow-up evaluation, 108 patients were available for clinical and roentgenographic examinations, amounting to a 79% follow-up rate. At follow-up examination, 67 joints (62%) were completely pain free and 28 joints (26%) caused slight pain on bearing weight. Walking ability was recovered moderately in RA and markedly in OA. In RA, 14 of 84 knees were cemented and one knee was treated with loosening. Of 72 cementless implantations, 55 sustained displacing distally and one sustained loosening in the tibia, whereas 31 sustained displacing proximally and six sustained loosening in the femur. In OA, 21 cementless knees had 17 displacings in the tibia, and ten displacings and two loosenings in the femur. Scanning electron microscopy (SEM) observation of the UHMWPE surface in tibial plates revealed smoothing and burnishing. Alumina is far superior to metal for the sliding part, although it is not always best for the portion in contact with the bone. To resolve these problems, for cementless fixation, anchoring portions of Ti alloy and alumina implants were covered with beads and coated with hydroxyapatite. For cement fixation, "the interface bioactive bone cement technique" interposing hydroxyapatite granules between bone and cement was performed.

Early Failure of Noncemented Porous Coated Anatomic Total Hip Arthroplasty

From July 1984 through October 1987, 63 consecutive primary Porous Coated Anatomic total hip arthroplasties were performed. Follow-up observation ranged from one to four years, with a mean of 2.4 years. The mean postoperative Harris hip score in 81 cases was 38% excellent results, 23% good results, 6% fair results, and 23% poor results. Eight percent of hips required revision of the femoral component related to subsidence. Persistent thigh pain was found in 33% and persistent limp in 58%. Poor clinical outcome was correlated with persistent thigh pain and 3 mm or more subsidence of the femoral component. Subsidence occurred despite adequate canal fill. This high percentage of early failure is unacceptable when compared with standard techniques of total hip replacements with cement fixation.

Bipolar Prosthetic Replacement for the Treatment of Avascular Necrosis of the Femoral Head

Eighty-three hips in 66 patients with nontraumatic avascular necrosis of the femoral head (ANFH) showing evidence of severe collapse or secondary osteoarthritic changes were treated with surgical implantation of bipolar hip prostheses either with or without cement fixation of femoral stems. The cases were observed for more than three years (range, three to ten years seven months; average, five years seven months) and assessed in terms of functional and roentgenographic results. These data were compared with the results of classic hemiarthroplasties using fixed head prostheses (Austin-Moore-type with curved or straight stem) that were performed at the authors' institutions before 1980. The results confirm that the clinical outcome is improved with use of the bipolar prosthesis. Satisfactory results (a score of 80 or greater on a hip function scoring system proposed by the Japanese Orthopaedic Association) were maintained throughout the follow-up period in most cases (71 of 83 hips) with the bipolar prosthetic replacements. In a group of patients with unsatisfactory results (12 hips), proximal migration of prosthetic head was seen in two cases. The incidence of proximal migration of bipolar heads, including those exhibiting minimal movement, was significantly lower when compared with that observed in an Austin-Moore-type head-fixed prosthesis group (7/83 versus 12/19) during a comparable postoperative follow-up period. It is noteworthy that the proximal migration of the bipolar head was not progressive, and, in most cases observed more than five years, the cartilaginous spaces of acetabulum were preserved, whereas in the Austin-Moore-replaced group, the migration was evident and progression occurred within three years of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of cement fixation on initial micromotion of the femoral component in condylar knee replacement.

Four fresh, cadaveric specimens were fitted with total knee replacements and mounted on a knee joint loading and measuring rig. Femoral component micromotion in the sagittal plane was measured with a transducer during flexion and extension of the specimen. Various condylar designs were used without and with cement. Movement followed a characteristic curve pattern and was less with cement fixation particularly for bone of low trabecular strength as determined by bone sample tests for stiffness. Cement fixation appears to be superior to cementless fixation.

Results of 203 total hip replacements using a smooth, cementless femoral component.

We implanted 203 smooth-stemmed femoral components before January 1988. The femoral component used was anatomically shaped, fluted and made of titanium. Thirty-two hips were revised due to mid-thigh pain, and the femoral implant was found to be loose in all. In the 157 patients with a two-year follow-up, the Merle d'Aubigné and pain scores for completely cementless arthroplasties were similar to those for hybrid prostheses (cemented acetabular cup and cementless femoral stem). Of the 145 cases with two-year radiographic follow-up, 59 had extensive radiolucencies and 22 were unstable. The five-year cumulative survival rate was 77%. Implantation of this stem should be restricted to patients in whom cement fixation is contra-indicated.

Distal femoral replacement with allograft/prosthetic reconstruction for treatment of supracondylar fractures in patients with total knee arthroplasty

Large-segment distal femoral allografts were used in conjunction with non-linked total knee prostheses to reconstruct bone deficits following supracondylar fracture of the femur in seven patients with previous total knee arthroplasties. Three patients with multiple medical problems died of unrelated causes prior to a minimum 2 year follow-up. Indications for surgery were previously failed attempts at osteosynthesis and significant fracture comminution, osteopenia, and intercondylar extension or femoral component loosening. Specifics of the surgical technique included subperiosteal excision of the involved distal femur with retention of a soft tissue sleeve containing the collateral ligaments and reconstruction with a large-segment allograft and a stemmed, semiconstrained total knee prosthesis. Cement fixation using pressurized technique with intramedullary plugging of the tibial and femoral canal was routinely used to secure the prosthesis/allograft construct to the host bone. Postoperative complications included one dislocation, which was successfully treated closed, and one popliteal artery injury, which was successfully repaired. There were no post-operative infections. Two patients, however, had some degree of persistent instability, warranting bracing at the time of last follow-up. Using the Knee Society rating system, the average knee score for these patients was 71, and the average pain score and function score were 33 and 49, respectively. Range of motion averaged 96°. All of the femoral components were well fixed at last follow-up. Results of this study indicate that large-segment distal femoral allografts used in conjunction with nonlinked knee prostheses can be an acceptable method of treatment of these difficult reconstructive problems.

Revision of cemented fixation and cement-bone interface strength.

Interfacial shear strength between poly(methyl methacrylate) (PMMA) bone cement and cancellous bone was measured in bone samples from human proximal femora. Samples were prepared with fresh cement-bone, fresh cement inside a mantle of existing cement and with fresh cement-revised bone surfaces. Push-out tests to measure shear strength caused failure only at bone-cement interfaces; revised bone interfaces were 30 per cent weaker (P < 0.02) than primary interfaces. The clinical relevance is that revision of cemented joint arthroplasties may necessitate removal of components with sound cement-bone fixation. The practice of removing all traces of PMMA cement may not yield the optimal fixation; adhesion of fresh cement to freshly prepared surfaces of the existing cement might also be considered where circumstances are favourable.

Hydroxyapatite-Coated Total Hip Replacement

Biologic attachment of load-bearing orthopedic implants has developed as a response to long-term problems associated with polymethylmethacrylate cement fixation. Although early clinical results of uncemented hip and knee implants have been encouraging, histologic studies of retrieved implants have shown a distinct lack of bone apposition and ingrowth. Hydroxyapatite (HA) coatings applied to metallic implant substrates have been shown to enhance biologic fixation. These results have led to the clinical investigation of the use of HA-coated total hip replacements.

Cement or Cementless Fixation in Total Knee Arthroplasty?

A prospectively studied group of 59 knees with cementless fixation were compared to a retrospectively studied but matched group of 59 knees with cement fixation using a Press Fit Condylar prosthesis. The only significant preoperative difference between the patient groups was mean age; the cemented group was on average nine years older than the cementless group (p less than 0.0001). At an average of 2.8 years after surgery, there were no significant differences in knee scores between the two groups. Radiolucent lines adjacent to the tibial component were similar in both groups. The complication rate of 20% in the cementless knees was higher than the 12% rate in the cemented knees; this was primarily related to polyethylene wear of metal-backed patellar components. Cement or cementless fixation of this prosthesis appears to provide equivalent early results.

Hybrid fixation modular tibial prosthesis

Abstract A prosthetic tibial component has been designed with features for fixation to bone using a combination of acrylic cement and ingrowth interfaces. This hybrid concept affords the component the immediate stability of cement fixation and the potential long-term stability of biologic fixation. The ingrowth interfaces (coupled with the central stem) are intended to shield the cement interface beneath the tibial tray from the tensile liftoff forces that result from eccentric loading, while avoiding the fretting and osteolysis associated with screw fixation. A disassembly capability allows the tray to be removed from the stemmed anchorage assembly, facilitating component extraction and limiting bone loss. A clinical and radiographic review of 50 consecutive primary total knee arthroplasties with a mean follow-up period of 35 months revealed stable interfaces with no progressive radiolucencies and minimal remodeling changes. The mean Knee Society knee score was 92.2. At final follow-up evaluation, 88.6% of patients noted no or mild (occasional) pain. Retrieval of three prosthetic knees with chronic sepsis showed extensive ingrowth into the porous interfaces and an osteointegrated bony sleave around the smooth central stem.

Total wrist arthroplasty: Review and update

Abstract The first articulated total wrist prosthesis in the United States was designed and implanted at the Arizona Health Sciences Center in 1974. Based on the original concepts of Charnley's total hip implant, the prosthesis was intended for cement fixation. However, early concern over the long-term durability of cement in the small bones of the wrist led to a natural reluctance of surgeons to use such an approach to treatment. Instead, most surgeons preferred to use a Silastic wrist spacer. Unfortunately, time has proven that use of such a device has led to two serious problems, ie, implant breakage and the production of erosive changes in adjacent bone caused by Silastic detritus and its resultant synovitis. Concerned that similar changes would arise from the use of cement, the author of this report has elected to press-fit the metacarpal component since 1978, continuing to cement only the radial component. His experience has been that gross lossening of the radial component with erosive changes to bone has been observed infrequently. Migration of the press-fitted metacarpal component has been observed especially in poorly balanced wrists and in patients with poor quality bone. More recently a newer modular design of a total wrist prosthesis, which is secured to both radial and metacarpal bone beds by a precision press-fit, has shown promise of pain-free function without the concerns of loosening or bone lysis. However, efforts in designing a more durable long-lasting wrist implant need to be continued because the preservation of a certain pain-free arc of motion is critical for many patients, especially in patients with advanced rheumatoid arthritis of the hand and wrist and in certain individuals whose occupation or vocation demands the preservation of wrist motion.

Schultz metacarpophalangeal arthroplasty: A long-term follow-up study

We describe a prospective, long-term evaluation of the Schultz metacarpophalangeal joint implant. The prosthesis is a semiconstrained, cemented implant with a ball-in-socket articulation. Thirty-six implants were followed for an average of 10.9 years. There was a progressive decrease in range of motion and strength and a recurrence of ulnar deviation. The neck of the proximal phalangeal component fractured in 39% of the joints. Periarticular heterotopic bone formed in all joints, but was extensive in only 22%. Although some lucency of the bone-cement interface was seen in 80% of the joints, no prosthetic loosening occurred in this series. Our results indicate that long-term, intramedullary cement fixation of relatively long-stemmed components can be satisfactory. However, the articulated portion of this implant does not consistently withstand the stresses transmitted across the joint and does not provide long-term joint stability.

Radiology of low-friction arthroplasty of the hip. A comparison of socket fixation techniques

We studied the radiographs of 211 low-friction arthroplasties, followed for five to 15 years after operation. The first 92 simple hemispherical sockets were fixed with an old technique: eburnated bone in the acetabular roof was removed and only a few large anchor holes were bored for cement fixation. With the next 119 sockets, 111 of which were flanged, the eburnated and subchondral bone was preserved and multiple small anchor holes were used. The modified technique and the use of flanged sockets significantly improved the late radiological findings as regards socket demarcation and wear. On the femoral side, the intramedullary canal filling ratio, the distal packing of cement, calcar resorption and atrophy of the femoral cortex were correlated with prosthetic subsidence.

Cementless hip replacement for arthritis. Problems with a smooth surface Moore stem.

We have analysed the clinical results of a cementless hip replacement using a Moore stem with a smooth surface, and correlated these results with the radiological changes. Forty-two consecutive arthroplasties in 41 patients were studied prospectively and reviewed at a minimum of two and up to six years; 63% had a good clinical result, 18.5% a fair result, and 18.5% a poor result. Thigh pain on weight-bearing was the main problem and was due to loosening of the stem. We caution against the use of this implant in arthritic patients, in whom a good result can be obtained more predictably with cement fixation.

The Rationale of Cementless Revision of Cemented Arthroplasty Failures

Patients with failed cemented total hip replacements develop minor to massive bone loss. In nearly all cases, the quality of the endosteal surface has been converted to a sclerotic tube. Because of the bone loss and the change in character of the remaining bone stock with which to form an interface with polymethylmethacrylate (PMMA), the microinterlock necessary for long-term interface stability cannot be achieved. Moreover, the first failure leads to the production of cement particles that incite a histiocytic osteolytic response. The difficulty in achieving interfacial stability in the revision setting is borne out in the published clinical results of cemented revision total hip arthroplasties showing failure rates ranging from 17% to 60.3%. Porous-surfaced prostheses have been introduced to permit biologic fixation as an alternative to cement fixation of each implant component. The good midterm clinical results and the lack of catastrophic bone loss when failure does occur have given impetus to the application of this technology to the revision situation. The preliminary clinical experience with cementless revision arthroplasty has yielded favorable results. The authors have fully developed the rationale against the use of PMMA in revision total hip replacements and for the cementless approach with porous-surfaced metal prostheses and bone grafts. The latter appear as a viable approach to a growing clinical problem.

Pressurized Cement Fixation in Total Hip Arthroplasty

In a follow-up study of 108 total hip arthroplasties, the 92% excellent and good results after seven to 11 years of implantation are evidence in support of cement fixation. The precision of the cementing technique is essential for a high percentage of successful results after ten or more years. Restricted reaming, brushing and lavage to remove debris, use of high-viscosity cement, and pressurization of the cement are of paramount importance.