Cemented Arthroplasty Research Articles

Use of Cemented Hemiarthroplasty for Femoral Neck Fractures.

Geriatric femoral neck fractures are common orthopaedic injuries, which are associated with a high morbidity and mortality. Arthroplasty is the optimum treatment for many of these injuries, but debate exists regarding optimal surgical strategy. Multiple recent investigations have demonstrated strong superiority for cemented stems as compared with noncemented fixation with a decreased risk of periprosthetic fracture, shorter length of stay, lower cost, and decreased rate for revision surgery. The main purpose of this article is to refamiliarize the resident or practicing surgeon with cemented arthroplasty by reviewing the basic science of cement, common cementing concerns, and outcomes, as well as by providing tips on cementing technique to ensure safe, simple, and reproducible results.

Impact of saline irrigation on the early mechanical characteristics and microstructure of bone cement

Very high heat is generated during the polymerization of poly (methyl methacrylate) (PMMA) bone cement, which is used for implant fixation in orthopedic surgery. As such, it has been suggested that irrigating the bone cement layer in the surgical site with a saline solution is a way of cooling the layer. In this study, we aimed to determine the influence of irrigation with a saline solution on the flexural strength and the microstructure of the test specimens of two PMMA bone cement brands: Simplex P and FIX 1. Specimens were assigned to three groups: (1) irrigation with normal saline solution at 25 °C (RS group), (2) irrigation with cold saline at 4 °C (CS group), and (3) no irrigation (control group). For each of the groups, the specimens were tested after various times of aging in phosphate-buffered saline solution (PBS) at 37 °C for 1 h, 24 h, and 7 days. Flexural strength was measured following ISO 5833 protocol, and the surface microstructure was determined using scanning electron microscopy (SEM). The flexural strength results showed that for each of the cement brands, the difference between the groups was not significant, except for Simplex P specimens aged for 24 h, for which flexural strength of the RS and CS group specimens was lower than in the control group. The microstructural features of the surface of the specimens were similar across groups. These findings suggest that in a cemented arthroplasty, irrigation of the bone cement for the purpose of cooling it must only be used after very careful consideration.

Use of Cemented Standard Stem Arthroplasty for Unstable Inter Trochanteric Fractures in Elderly Patients

Abstract Background The treatment of unstable intertrochanteric fracture in the elderly patient is still controversial. Traditionally, internal fixation using a dynamic hip screw was of choice. Recently, some authors advocated the use of cemented arthroplasty which results in better functional outcome. Aim and Objectives to assess use cemented standard stem arthroplasty for treatment of unstable intertrochnteric fractures in elderly patients to detect functional outcomes and complications. Subjects and Methods This was single arm clinical trial, was conducted in Ain Shams University Hospitals and Dar El-shefa hospital on 20 patients with unstable inter-trochanteric fractures in12 months. Result There was high statistically significant difference between Harris hip score at different periods. Conclusion Primary cemented arthroplasty is an effective treatment option for the unstable intertrochanteric femur fractures in the elderly when compared to open reduction and internal fixation. Cemented fixation is recommended in the elderly patients with osteopenic bone. Results of cemented arthroplasty in the treatment of unstable intertrochanteric femur fractures are affected by the age and sex of the patients, and medical comorbidities. Long term evaluation of the results of cemented arthroplasty in the treatment of unstable intertrochanteric fractures in elderly is recommended to assess the survivorship of the prosthesis and to evaluate the patient response to the cemented arthroplasty.

Hemodynamic Effects of Bone Cement Implantation in Hip Arthroplasty: Insights from a Prospective Study in Eastern India.

Bone cementation has various effects on hemodynamics including potentially fatal bone cement implantation syndrome (BCIS). Most of the studies on BCIS are from developed countries. We have studied the effect of bone cement on hemodynamics in hip arthroplasty in the eastern Indian population and compared it with the available literature. This prospective study was done by a team of orthopedic surgeons and anesthesiologists in a tertiary center in eastern India between March 2020 and December 2022. Seventy-two patients (Male 38: and Female 34) of age between 25 and 100 years fulfilling the inclusion criteria were included. In 43 patients (43/72, 59.72%) systolic and diastolic blood pressure fell in the range of 10 mmHg, in 22 patients (22/72, 30.56%) fall in blood pressure was in the range of 10-20 mmHg, and more than 20 mmHg fall in blood pressure were seen in seven patients (7/72, 9.72%). SPO2 decreased from 97-100% to 94-96% in 28 patients and 90-93% in six patients, which began to rise after 5 min of cementing and returned to normal after 10 min. Arrhythmias were seen in 16 patients with multiple comorbidity. Two patients had a cardiac arrest and one patient died after 6 h in the intensive care unit. Pre-operative evaluation, perioperative monitoring of hemodynamic parameters during cementing especially in high-risk patients with multiple comorbidities, and taking essential precautions during cemented arthroplasty are the key to preventing complications like BCIS.

Press-fit humeral implants in revision shoulder arthroplasty are as effective as cemented arthroplasty: a retrospective cohort study

BackgroundRevision shoulder arthroplasty (RSA) is an increasingly common procedure that can involve cemented or uncemented humeral implants. Although cement fixation is often advocated, it is not clear if the outcome is comparable to that of press-fit fixation. This study evaluated the survivorship and outcomes of cemented and press-fit humeral components in patients undergoing RSA at our institution. MethodsMedical records from adult patients who underwent RSA were reviewed retrospectively. Demographics and surgical data as well as subjective and objective outcome measures were collected. Patients were stratified into 3 groups according to their humeral revision type: cemented, uncemented, and retained stems. ResultsA total of 70 RSA patients with an average follow-up of 51.8 ± 43.9 months were included in the analysis: stems were cemented in 18.6% of the patients, uncemented in 61.4%, and retained in 20.0%. There were no significant group differences in patient characteristics. Follow-up data were available for 54 (77.1%) patients 2 or more years after RSA. There were no differences in patient-reported outcome measures among the groups. Active abduction at 1 year was greater for uncemented revisions than for cemented and retained stem components (128.9° ± 49.7° vs. 98.1° ± 55.7° and 100.8° ± 49.9°, respectively; P < .05). Patients in the uncemented and retained stem cohorts had greater strength in forward flexion, abduction, and external rotation than those in the cemented cohort, whereas patients in the cemented stem group had lower internal rotation strength at 1 and 2+ years of follow-up (P < .05). Postoperative radiographs indicated that none of the stems were at risk for failure. However, humeral bone loss was more common among those with uncemented stems (P = .02); in most of the cases, the loss was attributable to stress shielding. Survivorship of the implants did not differ among the groups, ranging from 91.1% to 92.3%. ConclusionPress-fit humeral components may be a viable option for RSA in patients with adequate humeral bone stock.

Treatment of intractable septic ankle arthritis with a continuous closed irrigation system.

The study aimed to evaluate the efficacy of a continuous closed irrigation system (CCIS) after open debridement for patients with intractable septic ankle arthritis. The retrospective study analyzed the intractable septic arthritis of 12 (6 males, 6 females; mean age: 64.1±14.7 years; range, 33 to 80 years) patients managed by CCIS between July 2015 and July 2020. All patients had previously undergone operations to treat septic ankle arthritis without resolution of the infection. After open debridement, the CCIS was usually equipped with two outflow tubes and one inflow tube. Saline inflow was about 1 L per day. The mean follow-up period was 30.8±14.9 (range, 15 to 70) months. The CCIS was maintained for a mean of 5.1±2.1 (range, 3 to 7) days. The mean number of operations the patients had previously undergone was 2.83±1.5 (range, 1 to 6). For 11 (91.6%) out of 12 patients, infection did not recur after one-time CCIS, and laboratory test results remained normal. Six patients had previously undergone total ankle replacement arthroplasty. These patients underwent antibiotics-mixed cement arthroplasty after CCIS. For five of six with infected total ankle replacement arthroplasty, infection did not recur after CCIS. However, one patient without the removal of both implants experienced recurrence at the same site after four postoperative months. In the reoperation, after the removal of both implants and the application of antibiotics-mixed cement arthroplasty, the infection was cleared. Use of CCIS after open debridement for intractable septic ankle arthritis is a good treatment option since it is relatively simple and safe, with good results.

Rate of Complications after Hip Fractures Caused by Prolonged Time-to-Surgery Depends on the Patient's Individual Type of Fracture and Its Treatment.

Hip fractures are common injuries in the elderly and are usually treated with timely surgery. While severe postoperative complications are reported for up to 10% of patients, many studies identified predictive factors for the occurrence of complications postoperatively. A controversially discussed factor is "time-to-surgery". The aim of the study was to examine if time-to-surgery was associated with the occurrence of complications and if the complication rate differed between the patient individual fracture types of intracapsular on the one hand and extracapsular hip fractures on the other hand. We hypothesized that time-to-surgery had less impact on complications in intracapsular hip fractures compared to extracapsular ones, and therefore, guidelines should pay attention to the patient individual case scenario. All patients who were admitted to the Department of Trauma and Orthopaedic Surgery of an academic teaching hospital for hip fracture surgery (n = 650) over a five-year period were included in the study. After the application of the exclusion criteria, such as periprosthetic or pathologic fractures, cases needed immediate surgical treatment, and after outlier adjustment, 629 cases remained in the study. Hip fractures were classified into intracapsular fractures (treated by hip arthroplasty) and extracapsular fractures (treated by intramedullary nailing osteosynthesis). The occurrence of severe complications in patients treated within 24 h was compared with patients treated later than 24 h after injury. For statistical evaluation, a multivariate logistic regression analysis was performed to investigate the impact of time-to-surgery interval on the occurrence of complications. Patients with an extracapsular fracture, which was treated with intramedullary nailing (44.5%), rarely suffered a serious complication when surgery was performed within 24 h after injury. However, when the interval of the time-to-surgery was longer than 24 h, the complication rate increased significantly (8.63% vs. 25.0%, p = 0.002). In contrast to this finding in patients with intracapsular fractures (55.5%), which were treated with cemented arthroplasty, complication rates did not depend on the 24 h interval (26.17% vs. 20.83%, p = 0.567). The occurrence of complications after surgical treatment of hip fractures is associated with the time interval between injury and surgery. A 24 h time interval between injury and surgical procedure seems to play a major role only in extracapsular fractures treated with osteosynthesis but not in intracapsular fractures treated with arthroplasty. Therefore, guidelines should take notice of the patient individual case scenario and, in particular, the individual hip fracture type.

Cement Pulmonary Embolism during Cemented Total Hip Arthroplasty: A Case Report and Review of Literature

Fractures of the femoral neck are the most frequent in elderly patients. They represent the most prevalent pathology in traumatology. Their incidence increases with age due to osteoporosis and the tendency to fall. Treatment is by cemented or uncemented arthroplasty. The use of polymethylmetacrylate cement provides primary stabilization of the implant and compensates for the poor bone quality in the elderly. However, the use of cement is not without complications and cement pulmonary embolism is one of the most serious complications. We report the case of a 64- year-old patient admitted to the Department of Orthopaedic and Traumatologic Surgery for a femoral neck fracture classified as Garden 2 and who underwent cemented arthroplasty complicated by cement pulmonary embolism and death.

RECONSTRUCTION OF THE TROCHANTERIC ZONE IN PRIMARY ARTHROPLASTY OF UNSTABLE PERTROCHANTERIC FRACTURES.

The aim: To justify the concept and features of acetabular reconstruction during primary endoprosthesis for transcatheter fractures from the standpoint of radiological data, biomechanical calculations and intraoperative observations. Materials and methods: A retrospective analysis of the use of primary cement arthroplasty for osteoporotic fractures of the trochanteric zone in 52 elderly and senile patients was conducted. Before implantation of the femoral component, fragments of the proximal metaphysis were fixed with cerclage tightening loops which depended on the type of fracture. For fractures 31-A2.1, 31-A2.2, 31-A2.3, reconstruction of the destroyed trochanteric zone and the walls of the bone marrow canal opening was performed using our own methodology. Finite-element modeling with the SolidWorks program was used to investigate the influence of the reconstruction of the trochanteric zone on the distribution of strain on the bone tissue around the implant under osteopenic conditions and load during single-support standing. Results: Clinical and X-ray results were studied in 39 (74.36%) operated patients within 3 to 33 months. There were no complications associated with recon-struction of the proximal part of the femur and implantation of endoprostheses. Restoration of movements in the hip joint and full loading of the operated limb was allowed the day after surgery, depending on the patients` physical condition. The results of finite-element modeling indicate a significant reduction of the strain on the proximal metaphysis in the zone of predominant destruction of the medial and posterior walls of the bone marrow canal of the trochanteric zone reconstruction and ensuring the stability of the femoral component. Conclusions: Clinical results and biomechanical calculations confirm the possibility and feasibility of using primary arthroplasty in unstable osteoporotic fractures of the trochanteric zone with the aim of early restoration of the support function of the damaged limb in individuals with limited physical capabili¬ties. Reconstruction of the intertrochanteric area with a ring-shaped autograft contributes to the achievement of primary stability of the femoral component, restoration of the total femoral offset and stabilizing function of muscles around the joints.

Favorable revision-free survivorship of cemented arthroplasty following failed proximal femoral nail antirotation: a case series with a median follow-up of 10 years

BackgroundGiven the ever-increasing rate of failure related to proximal femoral nail antirotation (PFNA), it is expected that an increasing number of PFNA individuals will undergo conversion to total hip arthroplasty (THA). The long-term survivorship of conversion of the initial PFNA to cemented THA is still debated. The aim of this retrospective study was to assess the long-term revision-free survivorship of cemented THAs after initial failures of PFNA in geriatric individuals.MethodsConsecutive geriatric individuals who underwent secondary cemented THA after initial PFNA fixation from July 2005 to July 2018, were retrospectively identified from three medical centres. The primary outcome was revision-free survivorship estimated using the Kaplan–Meier method and Cox proportional hazards regression with revision for any reason as the endpoint; secondary outcomes were functional outcomes and key THA-related complications. Follow-ups occurred at 3 months, 6 months, 12 months and then every 12 months after conversion.ResultsIn total, 186 consecutive patients (186 hips) were available for study inclusion. The median follow-up was 120.7 months (60–180 months) in the cohort. Kaplan–Meier survivorship with revision for any reason as the end point showed that the 10-year revision-free survival rate was 0.852 (95% confidence interval [CI], 0.771–0.890). Good functional outcomes were seen, and the HHS decreased markedly over the 24th month to the final follow-up interval from 92.2 to 75.1 (each p < 0.05). The overall rate of key THA-related complications was 16.1% (30/186).ConclusionCemented THA executed following initial PFNA failure may yield satisfactory revision-free survival and, at least for the initial 10 years after conversion, good functional outcomes and a 16.1% complication rate of key THA-related complications, which supports the trend towards increased use of cemented THA.

Pericapsular Nerve Group Block of the Hip Joint After Arthroplasty

We report a case of postoperative pain relief in a patient after total cement arthroplasty of the right hip joint in the early postoperative period. Pericapsular nerve group block (PENG-block) of the hip joint was suggested to provide adequate pain relief and reduce the risk of postoperative complications. This clinical case shows an example of effective pain relief in a patient in the early postoperative period after reconstructive plastic restoration of the right hip joint, performed for a fracture of the femoral neck. Severe pain syndrome, restriction of movements, forced position and volume of surgical intervention are risk factors for the development of thromboembolic complications. According to the literature, the incidence of thromboembolic complications after total cemented hip arthroplasty varies from 9.3 to 20.7%. Our observation indicates that pericapsular block of the hip joint is an effective method of pain relief in the early postoperative period after total hip replacement.

Implant survival of cemented arthroplasty following failed fixation of proximal femoral fractures in patients aged 30–60 years: a retrospective study with a median follow-up of 10 years

BackgroundGiven the unremitting growth in the volume of failed fixations of proximal femoral fractures (PFFs) in recent years, it is predictable that total hip replacements (THRs) will be the preferred surgical procedure. The long-term survival of cemented THR (CTHR) revisions remains controversial in patients aged 30–60 years. The goal of this retrospective review was to evaluate the 10-year survival of CTHRs following prior failed primary fixations of PFFs in patients aged 30–60 years.MethodsWe retrospectively identified CTHR revisions implemented at four medical centres during 2008–2017 for a failed primary fixation of PFFs in consecutive patients aged 30–60 years. The primary endpoint was implant survival calculated using the Kaplan–Meier method with 95% confidence intervals (CIs); secondary endpoints included functional scores assessed by Harris hip scores (HHS) and main revision-related orthopaedic complications. Follow-up was executed at 1, 2, 3, and 8 years following revision and then at 1-year intervals until the revision, death, or study deadline, whichever occurred first.ResultsIn total, 120 patients (120 hips) who met the eligibility criteria were eligible for follow-up. The median follow-up was 10.2 years (range, 8–12 years). Kaplan–Meier survivorship showed that implant survival with revision for any reason as the endpoint was 95% at 5 years (CI: 93–97%), 89% at 8 years (CI: 86–92%), and 86% at 10 years (CI: 83–89%). Patients treated with three hollow screws had better revision-free survival than patients treated with proximal femoral nail antirotation (PFNA), dynamic hip screw (DHS) or titanium plate plus screws (three p < 0.05). Functional scores were apt to decrease gradually, and at the final follow-up, the mean HHS was 76.9 (range, 67.4–86.4). The overall rate of main revision-related orthopaedic complications was 18.3% (22/120).ConclusionCTHR implemented following prior failed primary fixations of PFFs tends to afford an acceptable 10-year survival, along with advantageous HHS and a low rate of main revision-related orthopaedic complications, which may support an inclination to follow the utilisation of CTHRs, especially in revision settings for intracapsular fractures.

Similar outcomes including maximum knee flexion between mobile bearing condylar-stabilised and fixed bearing posterior-stabilised prosthesis: a case control study

PurposeProsthesis design influences stability in total knee arthroplasty and may affect maximum knee flexion. Posterior-stabilised (PS) and condylar-stabilised (CS) designed prosthesis do not require a posterior-cruciate ligament to provide stability. The aim of the current study was to compare the range of motion (ROM) and clinical outcomes of patients undergoing cemented total knee arthroplasty (TKA) using either a PS or CS design prosthesis.MethodsA total of 167 consecutive primary TKAs with a CS bearing (mobile deep-dish polyethylene) were retrospectively identified and compared to 332 primary TKA with a PS constraint, with similar design components from the same manufacturer. Passive ROM was assessed at last follow-up with use of a handheld goniometer. Clinical scores were assessed using Patient-Reported Outcome Measures (PROMs); International Knee Society (IKS) knee and function scores and satisfaction score. Radiographic assessment was performed pre and post operatively consisting of mechanical femorotibial angle (mFTA), femoral and tibial mechanical angles measured medially (FMA and TMA, respectively) on long leg radiographs, tibial slope and patella height as measured by the Blackburne-Peel index (BPI).ResultsBoth groups had a mean follow-up of 3 years (range 2–3.7 years). Mean post-operative maximum knee flexion was 117° ± 4.9° in the PS group and 119° ± 5.2° in the CS group (p = 0.29). Postoperative IKS scores were significantly improved in both groups compared to preoperative scores (p < 0.01). The mean IKS score in the PS group was 170.9 ± 24.1 compared to 170.3 ± 22.5 in the CS group (p = 0.3). Both groups had similar radiographic outcomes as determined by coronal and sagittal alignment, tibial slope and posterior condylar offset ratio measurements. When considering the size of tibial slope change and posterior-condylar offset ratio, there was no differences between groups (p = 0.4 and 0.59 respectively). The PS group had more interventions for post-operative stiffness (arthrolysis or manipulation under anaesthesia) 8 (2.7%) compared to 1 (0.6%) in the CS group (p = 0.17).ConclusionCondylar-stabilised TKA have similar patient outcomes and ROM at a mean follow-up of 3 years compared to PS TKA. Highly congruent inserts could be used without compromising results in TKA at short term.Level of evidenceLevel IV, retrospective case control study.

A Review of Bone Cements as Injectable Materials for Treatment of Bone-Related Diseases: Current Status and Future Developments

Increasing the average age of the population as well as sports injuries, bone-related diseases, such as osteoporosis, rupture or damage to cartilage and bone tissues, and bone fractures, has dramatically increased the need for repair and joint replacement surgeries. Biocompatible materials that are used as prosthetic stabilizers and bone fillers in orthopedic surgery are known as injectable bone cement (IBCs). Available clinical IBCs, such as polymethyl methacrylate and calcium phosphate cement are the most important of these materials. This paper presents the most popular substances for medical use. Although this replacement procedure reduces the pain and restores joint function, it is associated with several drawbacks that limit its efficiency and effectiveness, and sometimes patients should undergo revision surgeries. Recently, the development of the next generation of IBCs, which are bioactive and degradable with good mechanical properties, is of great interest. For the long-term clinical performance in cement arthroplasty, the next generation of bone cement with far greater mechanical and biological properties than acrylic bone cement on the market is required. As a result, new approaches and formulas have been developed using various techniques from different disciplines. This study summarizes the challenges, developments, and recommendations for the future. For this purpose, various literature from databases, such as ScienceDirect, SpringerLink, PubMed, and so on were consulted from 2000 to 2020.

Pulsatile Lavage Systems with High Impact Pressure and High Flow Produce Cleaner Cancellous Bone Prior to Cementation in Cemented Arthroplasty.

In cemented joint arthroplasty, state-of-the-art cementing techniques include high-pressure pulsatile saline lavage prior to cementation. Even with its outstanding importance in cementation, there are surprisingly few studies regarding the physical parameters that define pulsatile lavage systems. To investigate the parameters of impact pressure, flow rate, frequency and the cleaning effect in cancellous bone, we established a standardized laboratory model. Standardized fat-filled carbon foam specimens representing human cancellous bone were cleaned with three different high-pressure pulsatile lavage systems. Via CT scans before and after cleaning, the cleaning effect was evaluated. All systems showed a cleaning depth of at least 3.0 mm and therefore can be generally recommended to clean cancellous bone in cemented joint arthroplasty. When comparing the three lavage systems, the study showed significant differences regarding cleaning depths and volume, with one system being superior to its peer systems. Regarding the physical parameters, high impact pressure in combination with high flow rate and longer distance to the flushed object seems to be the best combination to improve the cleaning of cancellous bone and therefore increase the chances of a deeper cement penetration that is required in cemented joint arthroplasty. In summary, this study provides the first standardized comparison of different lavage systems and thus gives initial guidance on how to optimally prepare cancellous bone for cemented joint arthroplasty.

Regional or Neuraxial Anesthesia May Help Mitigate the Effects of Bone Cement Implantation Syndrome in Patients Undergoing Cemented Hip and Knee Arthroplasty for Oncologic Indications.

Bone cement implantation syndrome (BCIS) occurs during and after cementation of implants and is associated with hypotension, hypoxia, and cardiovascular collapse. In this study, we aimed to identify risk factors and potential mitigating factors of BCIS in the oncologic adult cohort undergoing cemented arthroplasty. We retrospectively reviewed oncologic patients aged 18 years or older who underwent cemented arthroplasty of either the hip or knee from 2015 to 2020. All implants were stemmed. We classified BCIS into three separate categories: (1) grade 1: intraoperative moderate hypoxia (<94%) or drop in systolic blood pressure >20%; (2) grade 2: intraoperative severe hypoxia or drop in systolic blood pressure >40%; and (3) grade 3: cardiovascular collapse requiring cardiopulmonary resuscitation. Demographics, primary malignancy diagnosis, intraoperative factors including cement timing, development of BCIS, 30-day postoperative outcomes, and mortality up to 2 years postoperatively were evaluated. Bivariate analyses and multivariate logistic regression were performed. Sixty-seven patients met inclusion criteria. Of these, 31 patients (46%) developed BCIS. No difference was found in age (65.5 versus 60.9 years; P = 0.15) or body mass index (28.8 kg/m2 versus 29.3 kg/m2; P = 0.76), comorbidities, intraoperative factors, or postoperative surgical outcomes between those who developed BCIS and those who did not (all; P > 0.05). An association with the type of anesthesia administered and development of BCIS in patients receiving general anesthesia alone (17/24 patients, 71%), neuraxial and general (4/15 patients, 27%), and regional and general anesthesia (10/28 patients 36%, P = 0.01) was found. Compared With neuraxial and regional anesthesia, general anesthesia alone had 5.8 (P = 0.007) and 4.5 times (P = 0.006) greater odds of developing BCIS, respectively. No differences were noted in rates of BCIS between regional and neuraxial anesthesia (P = 0.81). Addition of regional or neuraxial anesthesia may be protective in reducing development of BCIS in the orthopaedic oncologic cohort undergoing hip and knee arthroplasty. III.

Does Additive Pressurized Carbon Dioxide Lavage Improve Cement Penetration and Bond Strength in Cemented Arthroplasty?

The modern cementing technique in cemented arthroplasty is a highly standardized and, therefore, safe procedure. Nevertheless, aseptic loosening is still the main reason for revision after cemented total knee or cemented total hip arthroplasty. To investigate whether an additional carbon dioxide lavage after a high-pressure pulsatile saline lavage has a positive effect on the bone–cement interface or cement penetration, we set up a standardized laboratory experiment with 28 human femoral heads. After a standardized cleaning procedure, the test implants were cemented onto the cancellous bone. Subsequently, the maximum failure load of the bone–cement interface was determined using a material testing machine to pull off the implant, and the cement penetration was determined using computed tomography. Neither the maximum failure load nor cement penetration into the cancellous bone revealed significant differences between the groups. In conclusion, according to our experiments, the additive use of the carbon dioxide lavage after the high-pressure pulsatile lavage has no additional benefit for the cleaning of the cancellous bone and, therefore, cannot be recommended without restrictions.

Deep infection after hip hemiarthroplasty: risk factors for infection and outcome of treatments.

AimsDeep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.MethodsPatients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year.ResultsA total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection.ConclusionDeep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures.Cite this article: Bone Jt Open 2021;2(11):958–965.

Non-inferiority of The Cementless Total TKA Compared to The Cemented TKA, A m-Metanalysis

Objective: Cemented total knee arthroplasty still represents the reference standard in the field of prothesis knee replacement; but since cementless total knee arthroplasties were introduced there have been strong discussions over the years among cemented and non-cemented total knee arthroplasties to establish which gives the best benefits for the patient and for the surgeon.&#x0D; The purpose of this meta-analysis is to systematically analyze the use of cemented and cementless total knee arthroplasties by investigating clinical and radiological outcomes and rate of complications, in order to assess which techniques confers more benefits to the patient and the surgeon.&#x0D; Materials and Methods: The current systematic review has been written in accordance to the Cochrane handbook and the PRISMA statement for reporting of systematic reviews incorporating network.&#x0D; Results: Six randomized controlled trials were finally included in this systematic review. The statistical analysis revealed no significant differences in all clinical scores of interest (Knee Society Score, clinical and functional, Oxford Knee Score, Visual Analogue Score) and a similar revision rate.&#x0D; Conclusion: the results of the current metanalysis suggest the non-inferiority of cementless fixation with respect to cemented total knee arthroplasties in terms of clinical outcomes and survival rates of the implants.

Hybrid Oxford unicompartmental knee arthroplasty has lower residual cement extrusion than cemented arthroplasty in treating end-stage unicompartmental knee osteoarthritis

BackgroundHybrid Oxford unicompartmental knee arthroplasty (OUKA) consists of cementless femoral prostheses and cemented tibial prostheses. Although a hybrid OUKA has been used in clinical practice, the clinical outcome has not been reported. The purpose of this study was to compare the short-term clinical outcomes and rate of residual bone cement extrusion between hybrid and cemented prostheses and analyse the possible reasons for differences between outcomes.MethodsA total of 128 knees (118 patients) with end-stage osteoarthritis were included in this study, of which underwent consecutive operations using unicondylar Oxford phase 3 implants from July 2017 and September 2019 in our centre. Follow-up was performed at 6 weeks, 3 and 6 months, 1 year and every year after operation, and complications and changes in the Oxford knee score (OKS) were recorded. The OKS of the two groups was analysed by the generalized estimating equation approach. Prosthesis-based standard fluoroscopy was performed in a timely manner after each operation, and the rate of residual cement extrusion of the two groups was estimated using T-tests and a multivariate regression analysis.ResultsExcluding the cases that lost follow-up, a total of 120 knees (65 in hybrid group and 55 in cemented group) were included in the analysis. There was no statistically significant difference in patient characteristics between the two groups (p > 0.05). The average follow-up time was 23.4 months (and ranged from 12 to 38 months). As of the last follow-up, there were no complications, such as dislocation, fracture, prosthesis loosening and subsidence, but one patient in the cemented group experienced symptoms caused by residual loose cement. Postoperative OKS in both groups improved significantly (p < 0.001). There was no significant difference in the OKS at any point during the follow-up or in the improvement of the OKS between the two groups (p > 0.05). Residual cement was mainly extruded behind the tibial prosthesis. The rate of hybrid periprosthetic residual cement extrusion was significantly lower in the hybrid group than in the cemented group, and the difference was statistically significant (OR = 3.38; p = 0.014).ConclusionsHybrid OUKA is as effective as cemented OUKA in the short term after operation and can significantly reduce the residual cement extrusion rate around the tibial prosthesis.