Cement Restrictor Research Articles

The cemented stem in hip arthroplasty - state of the art technique and recommendations.

The indication for femoral stem cementation should be made on a patient-specific basis, taking physical activity, femoral geometry, and bone tissue quality into account. Age alone should not be the sole justification for cementation. The Dorr classification can serve as decision support for whether a cemented fixation should be used. Femoral neck fractures should generally be cemented. Familiarize yourself with the applied stem philosophy. Force-closed stems typically have a polished surface that allows for subsidence, especially in the first 2 years postoperatively. Stems following the shape-closed philosophy have rougher surfaces and do not allow subsidence. There are various types of cement that differ in viscosity and can be categorized accordingly. These cement types go through four temperature-dependent phases: mixing phase, waiting phase, working phase, and curing phase. Rough implants should be implanted quickly, using wetter cement. For a polished stem, the cement should be slightly firmer. To avoid complications like bone cement implantation syndrome, it is essential to adhere to the state-of-the-art retrograde cementation technique, which recommends pulsatile lavage and vacuum mixing of the cement. Additionally, cement restrictors and pressurizers are used. A thorough understanding of cementation techniques is crucial to ensure a favorable outcome with a uniformly thick cement mantle that encompasses the entire stem. Incorrect cementing can lead to the premature failure of the endoprosthesis.

Osteolytic change surrounding biodegradable cement restrictors used in total hip replacements mimicking malignancy

Peri-prosthetic osteolysis is a well-documented complication of total hip arthroplasty. A lesser-known form of peri-prosthetic osteolysis occurs specifically involving biodegradable cement restrictor devices which may be used in total hip replacements (THRs) to contain the cement material within the femoral medullary canal, which would help maintain adequate pressurization within the canal and secure the prosthetic femoral stem. The device is inserted into the femoral medullary canal just distal to the prosthetic stem. Different types of restrictors are used; certain biodegradables forms of restrictors are known to cause progressive osteolysis at the site of insertion, which can present as a gradually enlarging focal lytic lesion on imaging. While this entity as well as its relevance as a risk factor for peri-prosthetic fracture has been discussed in existing literature, the resemblance of this entity to a neoplastic process, particularly given the gradual enlargement over time is not well-documented. Understanding this process and potential pitfall when interpreting imaging, particularly X-rays, in patients who have previously undergone a THR, is important to avoid misdiagnosis of this otherwise benign entity as a neoplastic process and would potentially negate the need for unnecessary investigations.

Use of a Low Profile Ultra-High Molecular Weight Polyethylene Diaphyseal Humeral Cement Restrictor in Shoulder Arthroplasty.

When implanting a cemented humeral stem, a reliable method to prevent inappropriate extension and enable pressurization of cement in the intramedullary canal is required. The aim was to assess the outcomes of a dedicated humeral diaphyseal cement restrictor. In total 218 shoulders (207 patients) were included in the study, all of whom underwent a cemented total shoulder arthroplasty and a retrospective review was performed. The primary outcomes of interest were device stability in the medullary canal, successful occlusion of the canal, cement extrusion and quality of cement mantle. The majority of the cohort was female (63.3%) males and the average patient age was 71.7 years (SD 8.45). In 81.7% the device was deemed to be stable in the medullary canal. The device was significantly more stable in primary (84.2%) compared to revision cases (64.3%, p = 0.02). In 69.7% Barrack grade A mantle quality was achieved, this was higher in primary cases (74.2%) compared to revision cases (39.3%) (p = 0.00006). We noted excellent cementation outcomes using a cement restrictor specifically designed for the diaphyseal humerus anatomy. However, this humeral specific restrictor was noted to be more stable in primary as compared to revision cases.

1167 Assessing Femoral Cementing Qualities in Total Hip Replacements

Abstract Aim High quality cement mantles are important to the long-term survival of femoral stems in total hip replacements (THRs). There’s variability in the quality of cement mantles and positioning of cement restrictors. The audit aim was to assess current practice of cemented femoral stems in THRs against local standards. Method All patients who underwent THR with a cemented femoral stem between March 2021 and April 2022 were included in the study. TraumaCad software was used to retrospectively collect data on post-operative radiographs for overall cement mantle quality, coronal stem alignment, tip of stem to radio-opaque cement restrictor marker distance, and tip of stem to end of cement mantle distance (Gruen Zone 4). We audited against the following standards:90% of stems have Barrack and Harrison Grade A ratingKhalily angle <5°Tip of stem to radio-opaque marker of 20-40mmGruen zone 4 of 10-30mm Results 126 cemented femoral stems were included. Evaluation of Barrack grading showed 55% (N = 69) compliance with grade A, 45% (N = 57) of stems were grade B, with 0% grade C or D. Mean Khalily angle was 1.67° (98.4% compliance). Mean distance from tip of stem to cement restrictor was 36.5mm (60% compliance). Mean length of cement mantle in Gruen zone 4 was 18.9mm (71% compliance). Conclusions Overall, cement mantle quality and femoral stem coronal alignment were acceptable. There is variability of cement mantle thickness below the tip of the stem and with restrictor placement. We recommend re-auditing following junior surgeon cementing technique education.

What is the Safe Distance Between Hip and Knee Implants to Reduce the Risk of Ipsilateral Metachronous Periprosthetic Joint Infection?

Periprosthetic joint infection (PJI), the most common cause of revision after TKA and THA, is a devastating complication for patients that is difficult to diagnose and treat. An increase in the number of patients with multiple joint arthroplasties in the same extremity will result in an increased risk of ipsilateral PJI. However, there is no definition of risk factors, micro-organism patterns, and safe distance between knee and hip implants for this patient group. (1) In patients with hip and knee arthroplasties on the same side who experience a PJI of one implant, are there factors associated with the development of subsequent PJI of the other implant? (2) In this patient group, how often is the same organism responsible for both PJIs? (3) Is a shorter distance from an infected prosthetic joint to an ipsilateral prosthetic joint associated with greater odds of subsequent infection of the second joint? We designed a retrospective study of a longitudinally maintained institutional database that identified all one-stage and two-stage procedures performed for chronic PJI of the hip and knee at our tertiary referral arthroplasty center between January 2010 and December 2018 (n = 2352). Of these patients, 6.8% (161 of 2352) had an ipsilateral hip or knee implant in situ at the time of receiving surgical treatment for a PJI of the hip or knee. The following criteria led to the exclusion of 39% (63 of 161) of these patients: 4.3% (seven of 161) for incomplete documentation, 30% (48 of 161) for unavailability of full-leg radiographs, and 5% (eight of 161) for synchronous infection. With regard to the latter, per internal protocol, all artificial joints were aspirated before septic surgery, allowing us to differentiate between synchronous and metachronous infection. The remaining 98 patients were included in the final analysis. Twenty patients experienced ipsilateral metachronous PJI during the study period (Group 1) and 78 patients did not experience a same-side PJI (Group 2). We analyzed the microbiological characteristics of bacteria during the first PJI and ipsilateral metachronous PJI. Calibrated, full-length plain radiographs were evaluated. Receiver operating characteristic curves were analyzed to determine the optimal cutoff for the stem-to-stem and empty native bone distance. The mean time between the initial PJI and ipsilateral metachronous PJI was 8 ± 14 months. Patients were followed for a minimum of 24 months for any complications. The risk of ipsilateral metachronous PJI in the other joint secondary to a joint implant in which PJI develops can increase up to 20% in the first 2 years after the procedure. There was no difference between the two groups in age, sex, initial joint replacement (knee or hip), and BMI. However, patients in the ipsilateral metachronous PJI group were shorter and had a lower weight (1.6 ± 0.1 m and 76 ± 16 kg). An analysis of the microbiological characteristics of bacteria at the time of the initial PJI showed no differences in the proportions of difficult-to-treat, high virulence, and polymicrobial infections between the two groups (20% [20 of 98] versus 80% [78 of 98]). Our findings showed that the ipsilateral metachronous PJI group had a shorter stem-to-stem distance, shorter empty native bone distance, and a higher risk of cement restrictor failure (p < 0.01) than the 78 patients who did not experience ipsilateral metachronous PJI during the study period. An analysis of the receiver operating characteristic curve showed a cutoff of 7 cm for the empty native bone distance (p < 0.01), with a sensitivity of 72% and a specificity of 75%. The risk of ipsilateral metachronous PJI in patients with multiple joint arthroplasties is associated with shorter stature and stem-to-stem distance. Appropriate position of the cement restrictor and native bone distance are important in reducing the risk of ipsilateral metachronous PJI in these patients. Future studies might evaluate the risk of ipsilateral metachronous PJI owing to bone adjacency. Level III, therapeutic study.

Cementation in total hip arthroplasty: history, principles, and technique.

Total hip arthroplasty (THA) is a remarkably successful operation that has grown rapidly its utilization. Early modern THA constructs as developed by Sir John Charnley featured cemented femoral stems and acetabular components. The technique of cementing components for THA has evolved over time. Modern acetabular preparation requires exposure of the subchondral bone with appropriate cement penetration into the trabecular bone, whereas femoral preparation requires cleaning of the canal, cement restrictor placement, retrograde filling, and pressurization of the cement. When used appropriately, these techniques result in excellent long-term survivorship of implants and are also widely considered to be the ideal method of fixation for hip fractures. The purpose of this article to review the history, properties, techniques, and outcomes of bone cement utilization in THA.

Translated article] Efficacy of cement restrictors: Experimental study and development of a classification

IntroductionCement restrictors (CRs) are devices that allow occlusion of the femoral canal in order to obtain greater interdigitation of the cement between the bone and a better pressurization, which generates an increase in the survival of cemented stems. The aim of this study was to evaluate the efficacy of the different CRs used and propose a classification of this device. Materials and methodsAn experimental study was carried out, where 7 CR references of different designs and manufacturers were taken. Later, tests were carried out on 9 chlorinated polyvinyl chloride tubes for each reference, to achieve a total of 63 tests. ResultsIn our study, 34.9% of the CRs in ultra high molecular weight polyethylene failed, presenting migration and allowing cement to leak while none of the gelatin RC failed. ConclusionThe RC with an umbrella design proved to be the less effective, presented a higher incidence of migration and cement leakage, while the gelatin CRs were the best performers. Based on the results of this study, an analysis of the CR design was carried out and a classification was proposed that divides these devices into 2 types.

Improving the cementation of the tibial component in knee arthroplasty : a study of four techniques in the cadaver.

AimsThe main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray.MethodsIn order to determine the best tibial tray cementation technique, we applied cement to 40 cryopreserved donor tibiae by four different techniques: 1) double-layer cementation of the tibial component and tibial bone with bone restrictor; 2) metallic cementation of the tibial component without bone restrictor; 3) bone cementation of the tibia with bone restrictor; and 4) superficial bone cementation of the tibia and metallic keel cementation of the tibial component without bone restrictor. We performed CT exams of all 40 subjects, and measured cement layer thickness at both levels of the resected surface of the epiphysis and the endomedular metaphyseal level.ResultsAt the epiphyseal level, Technique 2 gave the greatest depth compared to the other investigated techniques. At the endomedular metaphyseal level, Technique 1 showed greater cement penetration than the other techniques.ConclusionThe best metaphyseal cementation technique of the tibial component is bone cementation with cement restrictor. Additionally, if full tibial component cementation is to be done, the cement volume used should be about 40 g of cement, and not the usual 20 g.Cite this article: Bone Joint Res 2021;10(8):467–473.

Hemiarthroplasty for geriatric femoral neck fractures

Restoration of pain-free joint function by implantation of abipolar hemiarthroplasty via anterolateral approach. Elderly multimorbid patients >70years, age >80years, low functional demand. Infection. Relative contraindications: dysplastic hip joint. Supine position. Anterolateral approach. Incision of the iliotibial tract and entering the interval between tensor fasciae latae muscle/gluteus medius muscle. Capsulotomy. Femoral neck osteotomy. Removal of the femoral head and determination of the size of the bipolar prosthetic head. Inspection of the acetabulum. Adduction, external rotation ("figure4" position) of the leg. Medullary preparation of the femur with rasps up to the correct level and size of the planed stem. Ensure the correct rotation of anteversion (10-15°). Trial reduction and examination of hip stability. Verification with image intensifier. Cement restrictor, jet lavage, drying the medullary canal, injection of bone cement and insertion of the prosthetic stem. Assembly/attachment of the definitive bipolar head to the stem. Reduction of the joint. Wound closure. Early mobilization and full weight bearing. Limitation of hip flexion >90°, rotation and adduction for 6weeks. Venous thromboembolism prophylaxis. Osteoporosis evaluation and management. Clinical-radiological control (after 6weeks, 1/3/5years). The implantation of acemented hemiarthroplasty using the anterolateral approach is amuscle-sparing and dislocation-safe surgical procedure with alow risk of revision, which enables early patient mobilization and agood hip joint function.

Hemodynamic changes in patients undergoing cemented total hip replacement surgery: a literature review

Cemented total hip arthroplasty is believed to offer adequate pain relief, satisfactory walking ability, and activities of daily living as one of the most widely used techniques for treating hip fragility fractures. However, some complications may occur perioperatively, not to mention the catastrophic bone cement implantation syndrome. Thorough assessment, perioperative monitoring, early detection, and treatment plays an essential role to maximalize the result of this procedure, as well as minimalizing morbidity and mortality. Some anesthetic measures that can be done in order to keep the stability of intraoperative conditions are avoiding volatile anesthetic agents in high-risk patients, administering 100% inspired oxygen throughout the procedure, invasive hemodynamic monitoring, and maintenance of normovolemia.A central line placement also provides a rapid route of drug administration if resuscitation becomes necessary. Orthopaedic surgeons should also consider thorough lavage of the femoral medullary canal, especially pulsatile jet lavage, removal of tissues before cementation to minimize the formation of microemboli during the procedure, and using cement restrictor to compartmentalize the bone marrow tissue and blood separately from the cement. Therefore, it can be concluded that understanding hemodynamic changes during this procedure is essential, not only for the operator but also for the anaesthesiologists.

Charnley femoral cemented stem with a permeable and resorbable cement restrictor and low-viscosity cement - Clinical and radiographical evaluation of 100 cases at a mean follow-up of 6.55 years.

Introduction: In 1979, in his first book dealing with low-friction arthroplasty (LFA), Charnley highlighted the use of a cement restrictor. Breusch and Malchau described in 2005 the “second-generation cementing technique.”The main objective of this study was to report on the clinical survival of 100 cases of Charnley femoral component implanted in 2007 and 2008 using a permeable and resorbable cement restrictor and a low-viscosity antibiotic-loaded cement.The secondary objectives were to analyze the complications and side effects and the accuracy of the device positioning.Material and methods: This was a monocentric retrospective review of a prospectively compiled database.Diaphyseal restrictor was biodegradable and permeable to gas, blood, and fluids to avoid intramedullary over pression during cementation. The cement was a low-viscosity antibiotic-loaded cement.Among 3555 patients, we selected the first continuous 100 cases of patients where we implanted the device.Survival probability was computed according to Kaplan–Meier method.Results: Mean follow-up was 6.55 ± 2.6 (range 1–11).Considering femoral component revision as the endpoint, survival rate was 100%.No patients died intraoperatively, none in the first month and the first year after surgery.No early periprosthetic fractures have been reported.Discussion: As described initially by Charnley, the use of a cement restrictor was highly recommended through the different generations of cementing techniques.Hypotensive episodes and cardiac arrest have been reported during cement insertion.In our series, we did not deplore any adverse effect related to the cementation.Conclusion: Our study demonstrates a 100% survival rate of a cemented femoral component without adverse effects when using routinely a resorbable and permeable cement restrictor and a low-viscosity cement. Bone cement is still a fantastic ally for the surgeon and the patients.

Humeral cemented revision: Techniques for safe extraction

Removing a well-fixed humeral component in revision shoulder arthroplasty can present a difficult challenge. Intraoperative complications including iatrogenic fracture, humeral perforation, segmental bone loss, nerve and soft tissue injury can occur. These complications can occur with both cemented and press-fitted stems and can lead to increased morbidity and decreased functional outcomes. Complete removal of the cement mantle and cement restrictor, when necessary, can present even further challenges. Several extraction techniques have been described that can help minimize complications and enable safe, complete component extraction.

A novel and bespoke absorbable cement restrictor.

A novel and bespoke absorbable cement restrictor.

Osteolytic changes around biodegradable cement restrictors in hip surgery

Background and purpose — Biodegradable cement restrictors are widely used in hip arthroplasty. Like others, we observed osteolytic reactions associated with a specific cement restrictor (SynPlug; made of PolyActive) and reviewed our patients.Patients and methods — We identified 703 patients with suitable radiographs from our database (2007 to 2012) who underwent cemented hip arthroplasty and received a SynPlug biodegradable cement restrictor. We reviewed all available radiographs to determine the incidence, severity, and progression of osteolysis. Mean postoperative follow-up was 1.8 (1–7) yearsResults — 1 year after implantation, the femoral cortex showed thinning by 12% in the anterior-posterior view and by 8% in the axial view. This had increased to 14% and 12%, respectively, at the latest available follow-up postoperatively (at a mean of 4 years). Cortical thinning of less than 10% was found in 37% of patients, but cortical thinning of 10–30% was found in 56% of patients. In the remaining 7%, a reduction of more than 30% of the original cortical thickness was observed.Interpretation — Osteolytic changes associated with the SynPlug biodegradable bone restrictors are inconsistent and highly variable. While some patients showed increased weakening of the femoral cortex with the potential risk of periprosthetic fracture, in others the degree of osteolysis only increased slightly or stabilized after 2 or more years. Any cortical bone loss after total hip replacement should be avoided, so the use of PolyActive biodegradable cement restrictors should be discontinued. Patients with a PolyActive cement restrictor in place should be followed up closely after surgery.

A Novel Minimally Invasive Technique for Treatment of Unicameral Bone Cysts.

Management of unicameral bone cysts (UBC) remain controversial. These cysts seldom heal spontaneously or even after pathological fracture. Sometimes these cysts can be very large and incredibly troublesome to the patient. Various treatments exist with variable success rates. We present our experience of treating these lesions by continuous drainage. Over a seven year period, six patients with unicameral bone cysts were treated by inserting a modified drain into the wall of the cyst. The aim of surgery was to place the drain in a dependent area of the cyst, through the cortex allowing for continuous drainage. This was achieved through a small incision under radiographic control. A cement restrictor (usually used for femoral canal plugging during total hip replacements) was modified and inserted to prevent closure of the drain site. A redivac drain was passed through the plug into the cyst. The drain was left in place for a week to establish an epithelialized pathway which hopefully would remain patent, into the subcutaneous tissues, after the drain had been removed. There were four males and two females in the group and the age range was 6 -12 years. Four of the lesions were in the upper humerus, one in the proximal femur and the other one in the proximal tibia. Healing was rated according to the modified Neer classification. Grade 1 (healed) and Grade 2 (healed with defect) was defined as excellent outcome. Persistent /Recurrent cysts (Grade 3 and 4) were noted as unsatisfactory. Five cases were completely healed. Only one had a further fracture and there were no recurrent fractures. All the patients reported complete comfort and they all were able to re-engage in recreational activities without restriction. We think that reducing the intra-medullary pressure in these lesions will lead to healing. We report a safe and minimally invasive technique for the management of UBC.

Osteolysis in cemented total hip arthroplasty involving the OptiPlug cement restrictor: more than an incident?

The case report of a severe osteolytic reaction surrounding the OptiPlug cement restrictor in a 74-year-old male patient initiated a retrospective case series and closer investigation into the OptiPlug and its active compound, PolyActive. Not only did we find several cases of severe osteolysis in our own study population of 284 patients, several articles have lately described potential harmful side effects of the PolyActive material in humans. Although none of the articles have been based on large databases, we cannot guarantee the safety of this product. More research would help in our understanding of this phenomenon. Until then, we cannot recommend the use of the OptiPlug cement restrictor.

Fracture of a Cemented, Highly Polished, Collarless, Triple-Tapered, High-Nitrogen Stainless Steel Femoral Stem: A Case Report.

Early cemented forged stainless steel and casted cobalt-chromium femoral components were susceptible to gross material failure1-7. Proposed risk factors include type of implant, surgical technique, and patient variables1-16. Advances in implant materials and design as well as surgical and cementing techniques have rendered implant fracture increasingly rare8. Modern high-nitrogen stainless steel (HNSS) alloys, such as ORTRON 90 (DePuy International, Leeds, United Kingdom), which is used in the C-STEM (DePuy, Warsaw, Indiana), are mechanically superior to previously used stainless steel alloys17. Although HNSS femoral stems are weaker than forged cobalt-chromium stems, they are widely used because of excellent clinical results and a dramatically lower cost16. Fractures of both types of stems are extremely rare but have recently been reported in the literature10,16. To our knowledge, this is the second reported case of a stem fracture in a C-STEM, a collarless, triple-tapered, highly polished cemented HNSS femoral stem16. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A sixty-nine-year-old man presented to one of the senior authors (A.S.) with pain in the left hip and thigh. Eleven years prior to presentation, he had undergone left total hip arthroplasty with a Duraloc 100 series (DePuy) titanium cementless acetabular shell (60-mm outer diameter) with an Enduron (DePuy) polyethylene liner (28-mm inner diameter, neutral, +4 mm offset) and a cemented C-STEM (size 6) femoral stem with an Elite (DePuy) zirconia head (28 mm, standard offset). A cement restrictor as well as an end cap and centralizer for the C-STEM had been used (Fig. 1). The patient also had undergone right total hip arthroplasty with a similar prosthesis ten years prior to this presentation. He was 5′10′′ …

Ten-year RSA-measured migration of the Exeter femoral stem

The Exeter femoral stem is a double-tapered highly polished collarless cemented implant with good long-term clinical results. In order to determine why the stem functions well we have undertaken a long-term radiostereometric analysis (RSA) study. A total of 20 patients undergoing primary Exeter total hip replacement for osteoarthritis using the Hardinge approach were recruited and followed with RSA for ten years. The stems progressively subsided and internally rotated with posterior head migration. The mean subsidence was 0.7 mm (95% confidence interval (CI) 0.5 to 0.9) at two years and 1.3 mm (95% CI 1.0 to 1.6) at ten years. The mean posterior migration of the head was 0.7 mm (95% CI 0.5 to 0.9) at two years and 1.2 mm (95% CI 1.0 to 1.4) at ten years. There was no significant cement restrictor migration. The Exeter stem continues to subside slowly into the cement mantle in the long term. This appears to compress the cement and the cement bone interface, contributing to secure fixation in the long term.

Localised bone grafting of acetabular cysts during total hip replacement

Bone cysts are commonly found when preparing the acetabulum during a total hip replacement (Fig 1). We describe a simple yet effective technique of localised bone grafting using the Exeter™ (Stryker, Newbury, UK) plug trials already available when using the Exeter™ total hip system (Fig 2). Figure 1 Anteroposterior x-ray of right hip with a superiorly located acetabular cyst Figure 2 Exeter™ plug trial head is ideal for bone graft impaction within cyst The Exeter™ plug trials used to measure cement restrictors can be employed to pack bone graft into cysts. They are supplied in diameters from 6mm to 20mm and allow the surgeon to choose the appropriate sized plug trial to fit the bone cyst for optimal impaction. The long T-handle allows this technique to also be applied in overweight patients with deeply located acetabuli.

Periprosthetic Femoral Fracture Due to Biodegradable Cement Restrictor

Biodegradable materials are gaining popularity in orthopedics. Despite finding use in different areas of orthopedic surgery, they do not come without disadvantages such as foreign body reactions, granulomatous reactions, and sterile sinus formation in bone. We report a case of a patient who sustained a periprosthetic fracture seen at the tip of a cemented femoral stem approximately 5 years postsurgery, secondary to the use of a biodegradable cement restrictor. There was no evidence of trauma or fall on the affected hip. To our knowledge, there has been no previous report describing periprosthetic fracture at the tip of cemented femoral stem secondary to the use of a biodegradable cement restrictor. We suggest abandoning use of these materials while performing cemented hip arthroplasties.