Cement Gun Research Articles

Comparison of different cementing techniques for cement penetration under tibial component in total knee arthroplasty: a retrospective observational study

PurposeThis study aimed to investigate the differences in cement penetration between cementing techniques in total knee arthroplasty (TKA).Materials and methodsWe retrospectively evaluated knee undergone TKA at our hospital for both preoperative and postoperative computed tomographic (CT) evaluations. Cementing was performed with hand mixing and hand packing (HM group) and with vacuum mixing and cement gun use (VM group). We measured the area under the tibial baseplate (sclerotic and nonsclerotic sides) and compared the mean and maximum depths of cement penetration at each area.ResultsOf the 44 knees evaluated, 20 and 24 knees were in the HM and VM groups, respectively. At the center of the sclerotic side, the mean penetration depths (2.0 ± 0.7 and 2.5 ± 0.7 mm, p = 0.02) and the maximum penetration depths (4.0 ± 0.9 and 5.0 ± 1.6 mm, p = 0.02) were significantly deeper in the VM group than in the HM group. The correlation between preoperative Hounsfield unit values and mean penetration were r = –0.617 (p < 0.01) and –0.373 (p = 0.01) in the HM and VM groups, respectively.ConclusionThe cementing technique of vacuum mixing and using a cement gun allowed for deeper cement penetration compared with the hand mixing and hand packing technique, even in bone sclerotic sites.

The Effect of Working Time and Application Technique on Cement Penetration into a Tibial Model

BackgroundAseptic loosening of the cemented tibial component is a source of failure in total knee arthroplasty. This study examined common techniques for cement application by quantifying depth and volume of penetration into tibia models. Material and methodsThirty-six composite tibia models were cemented with a tibial component using 3 application techniques (gun, osteotome, and layered) with either early or late cement working time. Computed tomography and 3D-modeling were used to quantify volume and depth of penetration. Statistical analysis was conducted with analysis of variance with Bonferroni correction and Student’s t-test. ResultsNo difference was found in overall volume of penetration between early and late cement application (P = .16). Beneath the baseplate, the layered technique had significantly less penetration and averaged less than 3 mm with early and late cement. The gun technique had the greatest depth of penetration with early cement and averaged greater than 3 mm in all zones regardless of cement working time. The osteotome technique achieved significantly greater depth of penetration around the keel with early and late cement, P < .01. ConclusionsUsing a cement gun ensures adequate penetration beneath the baseplate regardless of cement working time while the osteotome technique is effective to increase penetration around the implant keel. According to our study, applying cement early in its working time may not increase volume of penetration. This study raises concern regarding adequate cement penetration using the layered technique for cementing the tibial component in total knee arthroplasty, and future research is warranted.

Blood, sweat, and skins—and cement, and cinema, and searchlights: Carl Akeley’s adventures in inventing

Carl Akeley is a familiar figure in the world of museums, scientific exploration, conservation, and especially taxidermy—his innovations in that field in the early 20th century led peers to dub him ‘The Father of Modern Taxidermy’. But Akeley’s knack for innovation stretched far beyond mounting animal skins. As one colleague put it, ‘his practical mechanical resourcefulness was almost uncanny’. Akeley invented the ‘cement gun’ and sprayable concrete (aka ‘gunite’), a revolutionary movie camera embraced by Hollywood studios and documentarists, several ‘improved’ searchlight reflectors during World War I (when he was appointed a Consulting Engineer for the Army), and an assortment of other devices—more than 30 patents in all. One common thread tied all these efforts together: envisioning a problem, and devising a solution. This article presents an account of Carl Akeley’s inventive side, describing the wide array of inventions that grew from his natural mechanical aptitude, and his tireless passion to fabricate, and then improve.

A quantitative analysis of two cementing techniques in total elbow replacement: A cadaveric study.

One of the reasons for failure of total elbow replacement is loosening of the ulnar component. Cementing techniques are often outdated. A special small nozzle is needed for the ulnar component, when a cement gun is used. This may not always be available, or surgeons may prefer to use a syringe. We postulated that the use of a cement gun and smaller nozzle would result in improved filling of the ulnar canal. A cadaveric study was performed in which the ulnas of paired specimens were cemented with a cement gun or with a syringe. A 3D printed ulnar component was inserted and computed tomography scanning was performed on all specimens. Filling of the ulnar intramedullary canal was analysed using 3D reconstructions of the specimens. A greater degree of filling was seen by the use of the cement gun in 85.7%. Filling was 52.7% in the syringe group (25.1-78.7%), compared to 63.3% for the cement gun group (p < 0.05). The use of a small nozzle cement gun provided a significantly higher filling degree of the ulnar canal. We recommend to always use a cement gun with a specific small nozzle to cement the ulnar component in total elbow arthroplasty.

Small Diameter Cement Injection: A New Cementation Technique

Cementation is a very common practice in orthopaedic surgery. It is one of the few steps in orthopaedic surgery that is very time sensitive. Standard cement guns can access and easily fill long segments of diaphyseal bone. However filling narrow canals, such as a humerus, or a proximal femur in the presence of an existing femoral nail remain challenging due to the inability to introduce a standard cement tip into small spaces.

Cementing technique for primary knee arthroplasty: a scoping review

Background and purpose — The optimal cementing technique for primary total knee arthroplasty (TKA) remains unclear. We therefore performed a scoping review based on available studies regarding cementation technique in primary TKA and unicondylar knee arthroplasty (UKA).Patients and methods — A search in 3 databases identified 1,554 studies. The inclusion criteria were literature that studied cementing technique in primary TKA or UKA. This included cement application methods, full or surface cementing, applying cement to the bone and/or prosthesis, stabilization of the implant during curing phase, bone irrigation technique, drilling holes in the bone, use of suction, and the timing of cementation. 57 studies met the inclusion criteria.Results — The evidence was unanimously in favor of pulsatile lavage irrigation, drying the bone, and drilling holes into the tibia during a TKA. All studies concerning suction recommended it during TKA cementation. 7 out of 11 studies favored the use of a cement gun and no studies showed that finger packing was statistically significantly better than using a cement gun. There is evidence that full cementation should be used if metal-backed tibial components are used. Applying the cement to both implant and bone seems to give better cement penetration.Interpretation — There are still many knowledge gaps regarding cementing technique in primary TKA. There seems to be sufficient evidence to recommend pulsatile lavage irrigation of the bone, drilling multiple holes, and drying the bone before cementing and implant insertion, and applying cement to both implant and on the bone.

Cement Augmentation of Dynamic Hip Screw to Prevent Screw Cut Out in Osteoporotic Patients with Intertrochanteric Fractures: A Case Series.

PurposeThe purpose of this study is to describe a method of inserting cement in the femoral head before fixation with dynamic hip screw to prevent screw cut out due to osteoporosis and to evaluate its clinical outcome in these patients.Materials and MethodsIn this prospective study, 30 patients aged 60 years and older with intertrochanteric fracture were included. Bone mineral density was measured. After reaming of the femoral head and neck with a triple reamer and polymethyl methacrylate, bone cement was introduced into the femoral head using a customized nozzle and a barrel fitted on a cement gun. A Richard screw was inserted and the plate was fixed over the femoral shaft. Patients were mobilized and clinical outcomes were rated using the Salvati and Wilson's scoring system.ResultsMore patients included in this study were between 66 and 70 years old than any other age group. The most common fracture according to the Orthopaedic Trauma Association classification was type 31A2.2 (46.7%). The T-score was found to be −2.506±0.22 (mean±standard deviation); all patients were within the range of −2.0 to −2.8. The duration of radiological union was 13.67±1.77 weeks. Salvati and Wilson's scoring at 12 months of follow up was 30.96±4.97. The majority of patients were able to perform their normal routine activities; none experienced implant failure or screw cut out.ConclusionBone cement augmentation may effectively prevent osteoporosis-related hardware complications like screw cut out in elderly patients experiencing intertrochanteric fractures.

The Use of Bladder Syringe for Cement Application in Total Knee Arthroplasty.

There are various techniques of cement applications in total knee arthroplasty with a lack of clear consensus on best practice. The use of a bladder syringe as a reservoir and applicator of cement allows for minimal handling of the cement along with greater control and cost savings as compared with the manufacturer cement guns.

Novel modification of second generation intramedullary PMMA cementing technique for narrow upper and lower extremity canals.

It is very difficult to cement intramedullary canals smaller than 10mm with standard commercially available cement syringes due to mismatch in canal and syringe diameters. This is often encountered in children and in the upper limb. We describe a simple method of cementing, using cement gun with size-matched plastic endotracheal tube (ET). The medullary canal is prepared and the size determined. ET with outer diameter 0.5-1mm smaller than the canal diameter is chosen. The standard cementing syringe nozzle is cut at the middle and fitted to Portex(®) tube with the adaptor connector, which comes with the ET. The plastic ET is cut to an appropriate length depending on canal length to be cemented. The nozzle is fitted to the syringe and cementing done in the usual way. We applied this new modification in the method to cement narrow canals of ulna, humerus, tibia and femur. The method has proven to be consistently reliable and useful in cases of cementing stems into bones with narrow intramedullary diameters. Apart from femur and tibia in children, humerus and ulna in adults were also cemented. The cement mantle by this technique is uniform and uninterrupted. Special care should be taken to fit the connector properly to the syringe nozzle and to hold it firmly while cementing. In our experience, this new technique has proven to be very useful, easy to use, reproducible and effective in cementing narrow canals.

TKR without tourniquet: A laboratory study investigating the quality of the tibial cement mantle when using metaphyseal suction and cement gun

PurposeThe majority of cemented knee replacements worldwide are performed with a tourniquet. The benefits of surgery in TKR without a tourniquet have been well described but questions have been raised about the ability to prepare the bone for cementation, and take up of a tourniquet-less technique has been slow. A laboratory based model was constructed to directly compare the quality of cementing between tourniquet and tourniquet-less knee replacement supplemented by metaphyseal suction and a cement gun. MethodsA Sawbone model to represent the metaphyseal proximal tibia was constructed. The model allowed the inflow of simulated blood and the use of metaphyseal suction. The study compared four different techniques; the use of a tourniquet, no tourniquet, no tourniquet with cancellous suction and no tourniquet with cancellous suction and a cement gun. Each subtype of experiment was repeated 5 times. Quality of cementation was assessed using a calibrated engineering planimeter. ResultsThis model has shown that combining the use of metaphyseal suction and a cement gun but without the use of a tourniquet offers significantly better cement penetration (p<0.0001) than cementing using a tourniquetalone. ConclusionsThis study offers further invitro evidence to the argument that tourniquet-less surgery when supplemented by appropriate techniques can achieve a good cement–bone interface, whilst avoiding the additional risk of using a tourniquet to perform the procedure.

The Effect of Using a Cement Gun With a Narrow Nozzle on Cement Penetration for Total Elbow Arthroplasty: A Cadaveric Study

To compare the cement mantle characteristics associated with use of a narrow nozzle cement gun versus the use of a 60-mL catheter tip syringe. Twelve cadaveric distal humeri were cemented with either a cement gun or a syringe without canal occlusion. The humeri were sectioned and photographed. The corticocancellous junction and the outer margin of the cement mantle were analyzed digitally. The corticocancellous junction defined the available area for cement penetration. The outline of the cement mantle defined the actual area of penetration. The ratio of penetration to the available area was recorded for each slice. The mean ratio for each humerus was multiplied by the number of slices in that sample containing cement to calculate a cement index. The cement penetration ratios observed in cross-sections at the same level and the cement index were significantly greater with the use of the cement gun than with the use of the syringe. There was no difference in the number of slices that contained cement. The use of a cement gun with a narrow nozzle improved cement mantle characteristics compared with the use of a syringe when measured in a cadaveric model in the absence of canal occlusion. Improving cement mantle characteristics may decrease the incidence of aseptic loosening after total elbow arythroplasty.

An in vitro comparison of tibial tray cementation using gun pressurization or pulsed lavage

Aseptic loosening of the tibial component remains a limitation to the highly successful procedure of total knee arthroplasty (TKA). Pulsed lavage improves bone cement penetration and interface strength in tibial tray cementation. This study tested whether pressurized cement application with a cement gun can compensate the use of jet lavage for bone surface preparation. Tibial components were implanted in six pairs of cadaveric tibiae. On one side, pulsed lavage of the tibial bone was combined with finger packing of bone cement; on the other side, syringe lavage and gun cementing was used. Cement penetration into the bone was determined from computed tomography scans, and Interface strength was determined by pull-out testing. Cement penetration was greater (p = 0.004) and interface strength was higher (p = 0.028) in the pulsed lavage group. Pressurization of cement by gun application could not compensate for the omission of pulsed lavage. Thus, pulsed lavage should be considered a crucial factor in TKA to improve implant fixation, which cannot be compensated for by cement application technique.

Elbow Resection for Deep Infection After Total Elbow Arthroplasty: Surgical Technique.

Deep infection at the site of a total elbow arthroplasty is best managed with definitive removal of the components with resection arthroplasty in selected patients. Use a previous skin incision when possible, keep the subcutaneous flaps as thick as possible, and avoid inadvertent iatrogenic injury to the ulnar nerve. The location of the ulnar nerve may be unpredictable, and the radial nerve may be at risk in two different locations. Access the implants through windows on the medial and lateral aspects of the triceps; whenever possible, consider an extended olecranon osteotomy when the ulnar component and cement are well fixed. Removal of all retained cement after removal of the humeral component is critical. The ulna is much more delicate and fragile than the humerus and is prone to iatrogenic fracture. Send three separate samples for culture when there was at least one preoperative positive culture, and five samples when there were no positive preoperative cultures. Use the nozzles of cement guns to create cylinders of cement to be inserted in the ulna and humerus. For patients with compromised soft tissues, we often consult with a plastic surgeon prior to surgery to contemplate improved coverage with rotation or free flaps at the time of the resection arthroplasty. Early motion in an articulated brace may be allowed with a "stable" resection; unstable resections with substantial bone loss are best protected longer with no motion and may require a static brace. We recently reviewed the Mayo Clinic experience with resection arthroplasty for the treatment of infection after total elbow replacement. IndicationsContraindicationsPitfalls & Challenges.

Stand der zementierten Hüftendoprothetik in Deutschland 2010

The results of a national survey from 1998 showed that only around 10 % of orthopaedic surgeons in Germany had strictly implemented modern third-generation cementing techniques in total hip arthroplasty (THA). A 2005 update showed an improvement up to 29.4 %. The study was repeated in 2010 in order to evaluate the current situation and to determine whether modern cementing techniques have become more popular. A detailed, slightly modified questionnaire regarding cement and bone preparation, cementing techniques on acetabulum and femur, and implant types was sent to 492 German orthopaedic and trauma hospitals, as well as to visiting surgeons with an interest in THA. The survey was conducted over 6 months. The response rate was 51.8 %, 255 questionnaires were available for evaluation and statistical analysis. Palacos R+G bone cement remained the most widely used cement (52.2 %). The mixing times given varied significantly. Vacuum mixing systems have again become more popular (85.2 %). In the femur 78.6 % of the surgeons attempted to preserve cancellous bone and 77.8 % used pulsatile (jet) lavage. Retrograde cement application via a cement gun was done in 85.8 %. Cement restrictors were used in more than 98 %. Only 72.7 % of the surgeons implemented sustained cement pressurisation and preferred a cement mantle thickness over 2 mm (55.2 %). Only 18.1 % drilled multiple small acetabular keyholes and 66.5 % used jet lavage. In 67.9 % no cement gun was used and in 70.7 % the cement was applied at high viscosity. Cement pressurisation was done manually in 89.1 %. The Müller straight stem device remained the most popular implant. Only 7.4 % of the centres implanted less than 20 and 40.3 % more than 100 cemented stems per year, whereby higher THA volumes correlated with better cementing technique. The results of this survey demonstrate that, in comparison to 2005, the current state of cemented THA, in particular cementing technique has generally significantly improved. Future emphasis should focus on continued surgeon education and training, as the cementing techniques are of utmost importance for long-term durability.

Outcomes of Charnley total hip arthroplasty using improved cementing with so-called second- and third-generation techniques

BackgroundTechniques of cemented total hip arthroplasty have developed over time. We present the outcomes of Charnley total hip arthroplasty performed using improved second- and third-generation cementing techniques. MethodsWe reviewed the radiologic results of 91 Charnley total hip arthroplasties performed using second- and third-generation cementing techniques. Second-generation techniques involved making multiple anchor holes, a double-cementing method on the acetabular side and an intramedullary plug, and retrograde filling with a cement gun on the femoral side in 57 hips. Third-generation techniques involved additional vacuum mixing and cement pressurization in 34 hips. ResultsJoint survival rates at 20years when using second-generation techniques were 89% for the socket and 94% for the stem with aseptic loosening as the end point; the survival rates at 10years when using third-generation techniques were 97 and 100%, respectively. According to our radiographic evaluation system for the clear zone at 5years, there was less clear zone in the acetabular side with the third-generation techniques than with second-generation techniques. In the femoral side, there was very little development of the clear zone, but the difference between generations was not significant. ConclusionsSecond- and third-generation cementing techniques showed excellent survivorship. The clear zone scores at 5years indicated that third-generation techniques were effective, especially in the acetabular side, and may produce better long-term results than second-generation techniques.

Cementing the Tibial Component in Total Knee Arthroplasty: Which Technique is the Best?

Aseptic loosening of the tibial component remains a major cause of failure in total knee arthroplasty and may be related, directly or indirectly, to micromotion. Therefore, good fixation of the tibial component is a prerequisite to achieve long-term success of the implant. Cementing technique is one of the factors that play a role in this respect. We investigated the effect of different cementing techniques on the cement penetration in the proximal tibia. We compared 5 different cementing techniques in an anatomical open pore sawbone model (n = 25), using a contemporary total knee arthroplasty design and standard polymethylmetacrylate cement. We demonstrated that applying cement to both the undersurface of the tibial baseplate and as well as onto the tibial bone, either by a spatula or fingerpacking technique, leads to an optimal cement penetration of 3 to 5 mm. When cement is applied only onto the tibial component, penetration is insufficient. When a cement gun is used, cement penetration is too excessive.

Clinical and radiological results of calcium phosphate cement-assisted balloon osteoplasty for Colles’ fractures in osteoporotic senile female patients

BackgroundDistal radius fractures in osteoporotic senile female patients often used to be complicated with residual deformity, stiffness, and pain. Recently, however, adequate usage of a palmar locking plate or external fixation has led to fewer subsequent complications. The method proposed here deserves consideration because it is less invasive and more cost-effective. MethodsA total of 11 Colles’ type fractures (AO type A2) in 11 patients (all female; mean age 78 years) were treated. After a closed reduction, the fractures were fixed by percutaneous pinning, as Kapandji previously described. Through a 5-mm longitudinal skin incision on the dorsoulnar aspect of the fracture site, the barrel of a disposable 1-ml syringe was inserted into the fracture site as a port. Next, a pediatric uromatic balloon was introduced into the fracture site and inflated by contrast medium. The balloon inflation enlarged the void of the fracture site. A compression bandage around the fracture site was applied before calcium phosphate cement injection with a cement gun through the port under an image intensifier. The functional and radiological results were evaluated. The mean follow-up period was 16 months (range 12–25 months). ResultsAll results were graded as good or excellent within 3 months, and all were graded as excellent at the final follow-up. The average duration of immobilization was 4 weeks with a short forearm cast. The overall postoperative correction loss in ulnar variance was 1.7 mm. Radial inclination and volar tilt showed no postoperative correction loss. The final volar tilt, radial inclination, and ulnar variance were comparable to those of the nonaffected side. ConclusionsCalcium phosphate cement-assisted balloon osteoplasty is a less invasive procedure and can be clinically justified as a therapeutic option for a Colles’ fracture in osteoporotic senile female patients.

Use of Cement Gun for Fixation of Tibia Component in Total Knee Arthroplasty

We evaluated the efficacy of a cement gun to improve the depth of cement penetration in total knee arthroplasty. Ninety-one consecutive patients from two hospitals were recruited for this study. For Group I cement was applied to the tibial baseplate and the proximal tibia with fingers. Group 2 had similar application of cement to the tibial baseplate but cement was pressurized into the proximal tibia using a cement gun.. The knee was kept extended until the cement hardened. Standard post-operative x-rays were reviewed to assess cement penetration into the proximal tibia. The mean cement penetration was 2.1 mm in Group 1 and 3.1 mm in Group 2 and the difference was statistically significant. The use of the cement gun improves cement penetration into the proximal tibia and facilitates early stability of the implant fixation to the bone.

Cement venogram: As a Result of high Femoral Cement Pressurisation. A Report of 3 Cases

Current femoral cementing techniques for total hip arthroplasty (THA) have improved over recent years. High pressurisation is achieved using a cement gun with a proximal seal and a cement restrictor, maximising the microinterlock at the bone cement interface. However, there are concerns regarding over pressurisation of the femoral canal resulting in an increased risk of cardiorespiratory collapse secondary to embolic phenomena. We report on three cases over a one year period of cement within a vein (cement venogram) on a post-operative radiograph following THA. We feel that the cement venogram is an important indicator of high pressurisation and that its incidence may be on the increase with improved cementing techniques.

The Effect of Cement Gun and Cement Syringe Use on the Tibial Cement Mantle in Total Knee Arthroplasty

Evidence suggests that a thicker cement mantle improves fixation strength and resistance to tensile and shear forces in the tibial component of total knee arthroplasty. A low proportion of orthopaedic surgeons currently use techniques to improve cement penetration in the tibial plateau. We demonstrate that the use of a pressurized cement gun or cement syringe provides a highly statistically significant difference ( P < .001) to the depth of the tibial cement mantle and reduction in radiolucent lines when compared to cement applied by hand. This ensures a thicker cement mantle and may reduce the possibility of early failure by improving the strength of fixation and the resistance to tensile and shear forces. There is no statistical difference in the cement mantle produced by the cement syringe and the cement gun.