Cement Extrusion Research Articles

Ultrasound Examination for Cement Extrusion After Uni-Compartmental Knee Replacement.

A 66-year-old woman presented with persistent knee effusion three months after undergoing a cemented medial uni-compartmental knee replacement. She was afebrile and able to walk with a stick. Physical examination revealed moderate effusion. Radiographs showed posteriorly extruded cement, while computed tomography confirmed the absence of implant loosening but was unable to adequately visualize the adjacent soft tissues due to metallic artifacts. Ultrasound identified posterior cement extrusion beyond the femoral component, causing a delamination tear of the posterior capsule and indentation on the medial gastrocnemius. Knee arthrocentesis yielded 60 mL of blood-stained fluid with unremarkable analysis, and the patient reported improvement following the procedure. To our knowledge, this is the first report to highlight the unique role of ultrasound in detailing the anatomy of extruded cement and its impact on adjacent soft tissues following knee replacement. We demonstrate the critical structures that should be evaluated and how ultrasound aids in managing this postoperative complication.

Comparison of outcomes of dual-mobility cemented total hip arthroplasty versus bipolar cemented hemiarthroplasty in patients with femoral neck fractures

Background: Elderly people with femoral neck fractures are more likely to experience complications after hip replacement. Compared with total tripolar hip arthroplasty (THA), bipolar hemiarthroplasty (HA), more effective alternative treatments that improve overall safety. We aimed to review the benefits of dual mobility tripolar arthroplasty and compare it to bipolar hemiarthroplasty in treatment of the femoral neck in the elderly. Methods: This study was conducted as a comparative randomized controlled prospective study. Patients were divided randomly to two equal groups 19 patients each one group underwent cemented bipolar hip hemi arthroplasty and the other group underwent cemented tripolar total hip arthroplasty, surgical approach for the two study groups was modified lateral Hardinge approach. The patients were followed up after one month, three months 6 months and one year. The follow up period was one year, and modified Harris hip score was reported, and radiograph scan of fracture site was done before and after surgery. Complications were reported whether intraoperative or in the follow up period. Results: The result of the study showed that the operative time was much longer in tripolar group as compared to bipolar group, there was more blood loss in tripolar group more than bipolar group. The functional outcome assessed using Harris hip score showed better outcome in tripolar group as compared to bipolar group. As regard complication, there was one case of periprosthetic fracture intraoperative in bipolar group and one case of cement extrusion in tripolar group. There was no dislocation in both groups. Conclusions: Tripolar total hip arthroplasty had better functional outcome than bipolar hip hemiarthroplasty and we recommend more studies for a longer period of follow up to assess rate of complications and functional outcome on the long run.

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.

Cause for concern? Significant cement coverage in retrieved metaphyseal cones after revision total knee arthroplasty

BackgroundMetaphyseal cones are used to manage bone loss in revision total knee arthroplasty with increasing popularity. Post-operative radiographs and explant procedures suggest that cement may extrude around the cone implant into the cone-bone interface and prevent biologic in- or on-growth. The purpose of this study was to perform a retrieval analysis to describe the pattern of direct cementation onto the porous surface area of metaphyseal cones. MethodsEighteen tibial and femoral cones were identified in an institutional implant retrieval registry. Anterior, posterior, medial and lateral quadrants were digitally mapped for direct cementation, bone ongrowth and fibrous ongrowth were calculated as a percentage of the porous surface area. Plain radiographs from prior to cone explant were analyzed for the presence of cement in all four quadrants and compared with results of the retrieval analysis. ResultsMean bone ongrowth was 25%, direct cementation was 24% (31% in tibial cones) and fibrous ongrowth was 29% of the porous surface area of the retrieved cones. There were no significant differences when comparing patterns of bone or fibrous ongrowth or cementation between anterior, posterior medial and lateral porous surfaces for tibia cones, femoral cones or all cones grouped together. Plain radiographs significantly underestimated the amount of cement covering the cone (p = 0.02). ConclusionIn this retrieval study, we found significant cement extrusion around the porous surface of metaphyseal cones in revision TKAs. Optimizing the cone-bone interface may reduce the risk of cement extrusion and theoretically reduce the risk of aseptic loosening.

Cement leakage during vertebroplasty: comparison between intact and wall disruption in spinal metastases.

Percutaneous vertebroplasty (PVP) is an effective measure for painful metastases or impending pathological fractures of the spine with cement leakages being the most frequent complication. Posterior extrusion of cement into the spinal canal may result in neurological symptoms and deficits. To compare the occurrence of intraspinal canal cement leakage between vertebrae with posterior wall disruption and vertebrae without posterior wall disruption. A single-center retrospective study was conducted of all PVP for spine metastases between June 2020 and November 2021. All leaks were analyzed by a postprocedural computed tomography scan or cone-beam computed tomography. A total of 77 patients with 143 vertebrae treated by PVP were included. Posterior wall disruption was observed in 64 (44.8%) vertebrae while 79 (55.2%) had a complete posterior wall. Spinal canal cement leakage occurred in 36 (25.2%) vertebrae and was comparable in both groups, occurring in 16 (25.0%) vertebrae with posterior wall disruption and 20 (25.3%) vertebrae without posterior wall disruption (P = 1). No risk factors for spinal canal leakage were found in the univariate and multivariate analyses. One spinal leak was symptomatic with intercostal neuralgia. Our results suggest that an incomplete vertebral posterior wall does not increase the rate of spinal canal cement leakage during PVP.

The role of Vertebral Augmentation Procedures in the management of vertebral compression fractures secondary to multiple myeloma.

Multiple myeloma (MM) is a systemic disorder characterised by proliferation of B-lymphocytes and plasma cells in the bone marrow. The primary aims of the management of spinal lesions in MM are pain control and fracture stabilisation. Vertebral augmentation procedures (VAP) can be subdivided into percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP). BKP involves the placement of orthopaedic balloons into the fractured vertebral body, creating a void into which polymethylmethacrylate bone cement is injected. This review outlines the management of spinal lesions in patients with MM, with a focus on the comparative risks and efficacy of vertebroplasty (VP) and balloon kyphoplasty (BKP). Soft tissue masses in MM are highly radiosensitive. Bisphosphonates and newer oncological therapies have decreased the indications for palliative radiotherapy, while spinal bracing can be utilised in selected cases to provide stability. BKP and VP provide equivalent long term pain control after MM vertebral compression fractures (VCF). BKP is superior to non-operative management and VP for restoration of vertebral body height and prevention of segmental kyphosis. Current evidence suggests a greater degree of correction of kyphotic deformity and restoration of mid vertebral height (MVH) with BKP when compared with VP. The literature supports the use of BKP even in the presence of posterior vertebral body wall (PVBW) fractures, a group previously considered a contraindication to VAP. Superior functional outcomes have been reported in patients undergoing early versus delayed BKP (<6-8weeks). Current evidence supports a lower risk of cement extrusion with BKP than with VP, but serious complications following VAP are rare. MM spinal pathology should be managed in a multidisciplinary setting. Surgical decompression and instrumentation are rarely indicated, due to the radio-sensitivity of soft tissue lesions in MM. BKP is a safe and effective procedure for VCF secondary to MM.

Should the vent hole of posterior implant crowns be placed on the lateral surface? An in vitro study of the hydrodynamic feature of cement extrusion and retention ability.

Although placing a vent hole on the occlusal surface of the implant crown can reduce cervical marginal cement extrusion, it has disadvantages. Transferring the hole to the buccal or lingual surface of the posterior implant crown could therefore be an alternative solution. This study investigated the effect of transferring the vent hole to the lateral side of the implant posterior crown on the hydrodynamics of excess cement extrusion and the crown’s retention ability. Specially fabricated posterior implant crowns were divided into five groups: crowns with an occlusal hole (OH), occlusal lateral hole (OLH), middle lateral hole (MLH), cervical lateral hole (CLH), and no hole (NH). Each set of implant analog-abutment-crown specimens was wrapped in a polymethylacrylate base. The base of the implant crown was divided into four 90-degree quadrants along the diagonal of the square base with a pen mark. Cement was used to bond the crowns and the abutments, and the weight of cement extrusions at the vent holes and the abutment cervical margins were calculated. The distribution of cement extrusion at the margin was photographed in each quadrant, and the areas of surface coverage of cement extrusion were compared with ImageJ software. Retentive strength was measured as the dislocation force using a universal testing machine. One-way analysis of variance was used for result analysis. The cervical marginal cement extrusions of crowns with lateral holes (OLH, MLH, and CLH) were significantly less than that of NH crowns (P<0.05), but more than that of OH crowns (P<0.05). Subgroup analysis among the lateral hole groups indicated that the higher the position of the lateral hole, the lower the weight of the cement extrusion, and the smaller the total distribution area of cement extrusion. The cement extrusion distribution area was larger in the quadrant with the hole than in those opposite and next to the hole. Retention strength comparison indicated no significant difference between crowns with NH, OH, or lateral holes. Transferring the vent hole of the posterior implant crown to the lateral side could reduce cement extrusion at the cervical margin while reducing retention strength deterioration and the esthetic drawbacks caused by occlusal hole opening.

Iatrogenic Extrusion of Calcium Silicate Cements on Teeth Associated with Large Periapical Lesion: A Case Report with 12-Month Follow-up

Traumatic dental injuries can result in pulp necrosis and apical periodontitis, impairing root development. When this condition is left untreated, it causes inflammation in the tissues at the apex, which may lead to significant damage of the periapical alveolar bone. Tooth with open apex may have a risk of iatrogenic error of extrusion material during the stage of root canal obturation. Objective: This case report discussed the bone healing of large periapical lesion of an iatrogenic extrusion of calcium silicate cement in an open apex maxillary left central incisor. Case report: A 35-year-old female patient presented with a main complaint of a discoloured upper front tooth that was affecting with her appearance. Clinical examination showed her left maxillary central incisor was diagnosed with pulp necrosis and symptomatic apical periodontitis. Periapical radiograph revealed the tooth has an open apex and large periapical lesion. After chemomechanical disinfection, an apical plug was placed with bioceramic material. Periapical radiographs taken postoperatively demonstrated the extrusion of bioceramic material into the periapical lesion. After a year, the tooth does not exhibit any symptoms, and periapical radiographs showed that the periapical region has totally healed. Conclusion: Extruded bioceramic material has no detrimental impact on periapical tissue healing, as evidenced by 12-month follow-up observations.

Selection of 1-mm venting or 2.5-mm screw access holes on implant crowns based on cement extrusion and retention capacity

BackgroundThis in vitro study aimed to provide evidence regarding the selection of hole diameters of implant crowns to reduce excess cement extrusion at the abutment margin, and to examine the maintenance of their retention capacity in anterior and posterior cement-retained implant crowns.MethodsSix groups of implant crowns were prepared according to the position of the teeth and the size of their holes as follows: anterior crown without hole (ANH), anterior crown with 1-mm mini venting hole (AMH), anterior crown with 2.5-mm regular screw access hole (ARH), posterior crown without hole (PNH), posterior crown with 1-mm mini venting hole (PMH), and posterior crown with 2.5-mm regular screw access hole (PRH). Temporary cement was used to bond the crowns to the abutments. The mean amount of excess cement extrusion among the different groups at the abutment margin was calculated. Retentive strength under different hole designs was measured as the dislocation force of the crown using a universal testing machine. One-way ANOVA and Welch’s t-test were used to analyze the results.ResultsThe average amounts of extruded excess cement were 18.96 ± 0.64, 1.78 ± 0.41, and 1.30 ± 0.41 mg in the ANH, AMH, and ARH groups, respectively, and 14.87 ± 0.36, 1.51 ± 0.40, and 0.82 ± 0.22 mg in the PNH, PMH, and PRH groups, respectively. The hole opening in the crowns could significantly reduce residual cement regardless of its size (p < 0.001). The mean retentive strengths were 54.16 ± 6.00, 47.63 ± 13.54, and 31.99 ± 7.75 N in the ANH, AMH, and ARH groups, respectively, and 57.84 ± 10.19, 53.22 ± 6.98, and 39.48 ± 5.12 N in the PNH, PMH, and PRH groups, respectively. The retention capacity of the implant crown deteriorated rapidly as the holes on the crown surface enlarged.ConclusionsThe presence of a hole on the implant crown reduced the amount of excess cement. The retention ability of the implant crowns deteriorated as the size of the hole increased. Considering the esthetic effect of the crown and the possible influence on crown retention, an implant crown with a 1-mm mini venting hole is a better clinical choice than the one with a 2.5-mm regular screw access hole.

Ultrasound-guided Tenotomy and Osteectomy for the Treatment of Iliopsoas Impingement Post-total Hip Replacement

Ultrasound-guided Tenotomy and Osteectomy for the Treatment of Iliopsoas Impingement Post-total Hip Replacement

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.

Evaluation of refined cement-based matrix systems for extrusion of wood fiber cement

Different cementitious matrix formulations incorporating various chemical, polymeric and mineral additives were evaluated for use in extruded fiber cement products. These alternative formulations were designed to enhance the end product performance characteristics under aging conditions and to facilitate the extrusion process. The impact of different matrix formulations on mechanical, durability and physical characteristics of extruded cellulose fiber cement products were compared. Test results show that most of the additives lowered the bulk specific gravity but increased the moisture absorption capacity of extruded fiber cement products when compared with the basic mix formulation. Generally, the additives caused drop in flexural strength but did not significantly affect the flexural toughness of the matrix formulations. Upon saturation the frictional pull-out of swollen fibers increased the ductility (deformation) capacity of extruded cellulose fiber cement products. These results provide further insight into performance characteristics of extruded cellulose fiber cement products, and help with selection of matrix mix formulations to meet performance requirements of a particular application.

Cement arteriovenogram after hip arthroplasty

Modern cement implantation techniques during hip arthroplasty rely on high intramedullary pressures which can result in cement extrusion towards femoral nutrient vessels, and thus, the occurrence of a particular image in postoperative radiographs (bone cement arterio-venogram).We report a case series of 14 patients in whom a bone cement arterio-venogram was observed after undergoing a cemented hip arthroplasty. No local or systemic complications developed after cementing nor during a mean follow-up of three years.Bone cement arterio-venogram is a radiologic sign that indicates a good cement pressurisation during surgery and is not associated to medical complications or periprosthetic femoral fractures.

Arteriovenograma de cemento óseo en artroplastia de cadera

Modern cement implantation techniques during hip arthroplasty rely on high intramedullary pressures which can result in cement extrusion towards femoral nutrient vessels, and thus, the occurrence of a particular image in postoperative radiographs (bone cement arterio-venogram).We report a case series of 14 patients in whom a bone cement arterio-venogram was observed after undergoing a cemented hip arthroplasty. No local or systemic complications developed after cementing nor during a mean follow-up of three years.Bone cement arterio-venogram is a radiologic sign that indicates a good cement pressurisation during surgery and is not associated to medical complications or periprosthetic femoral fractures.

An auxiliary device for screw-retained fixed implant restorations which prevents extrusion of cement into screw-access openings

For screw-retained fixed implant prostheses, the cement that extrudes onto the margin can be easily removed, but the cement that may intrude into the screw-access opening (SAO) during the extraoral bonding process is difficult to eliminate. This article presents a manufactured auxiliary device that is applied to the extraoral bonding process of screw-retained fixed implant prostheses. This device will prevent excess cement from being left in the SAO.

Vertebral body cemented stents combined with posterior stabilization in the surgical treatment of metastatic spinal cord compression of the thoracolumbar spine.

Background: Extensile interventions to provide anterior spinal column support in metastatic spinal cord compression (MSCC) surgery incur added morbidity in this surgically frail group of patients. We present our preliminary results of posterior spinal decompression and stabilization coupled with vertebral body cemented stents for anterior column support in MSCC.Methods: Fourteen patients underwent posterior spinal decompression and pedicle screw construct along with vertebral body stenting (VBS) technique for reconstruction and augmentation of the vertebral body. The primary in all except one was solid organ malignancy and 10 patients (71%) were treatment naïve. The mean revised Tokuhashi score was 10.7 ± 2.7 and the mean spinal instability neoplastic score was 9.6 ± 1.9. All vertebral body lesions were purely lytic and were associated with a cortical defect in the posterior wall.Results: A mean 5.3 ± 2.7 ml low-viscosity polymethyl methacrylate bone cement was injected within the stent at each compression level. No cement extrusion posteriorly was noted in any case from intraoperative fluoroscopy or postoperative radiographs. Five patients died at a mean 6.8 months (range 1–15 months), while the remaining patients have a mean survival of 18 months. Neither further revision surgical intervention nor any neurological deterioration was noted in any patient, who all continued to be ambulatory. The mean postoperative Core Outcome Measures Index score for 11 patients was 4.03 (standard deviation 3.11, 95% confidence interval (1.93–6.12).Conclusion: In lytic vertebral body lesions with posterior wall erosions, cemented VBS technique adds to the surgical armamentarium in MSCC surgery showing promising early results without added complications.

Venous Drainage of Lumbar Vertebral Bodies: Anatomic Study with Application to Kyphoplasty, Vertebroplasty, and Pedicle Screw Complications

Bone cement augmentation with polymethylmethacrylate is a reliable method for stabilizing osteoporotic compression fractures and improving fixation of pedicle screws. However, cement extrusion into the vertebral venous system can result in pulmonary cement embolism. The goal of this anatomic study was to identify the relationship between the internal/external vertebral plexus and neighboring abdominal caval system. Thirty-two lumbar vertebral levels were used in this study. Anterior abdominal dissection was performed to access the lumbar vertebral bodies through the peritoneal cavity, and a 16-gauge needle was placed into the center of each lumbar vertebral body at its anterior aspect. Fluoroscopy was used to confirm if the needle was correctly placed. Next, latex and/or continuous air injections were performed into each lumbar vertebral level (L1-L5). Observations confirmed if the latex or air traveled into the inferior vena cava. In addition, the spinal canal was opened to see if any latex was found to enter inside the vertebral canal in cadavers injected with the latex. Latex or air was found to flow into the inferior vena cava at all the lumbar vertebral levels. The latex/air was not observed in the spinal canal in any specimen. An exact knowledge of the lumbar vertebral venous anatomy is essential when procedures that could affect the vertebral venous system are involved. Its complexity and anatomic variability necessitate such an understanding to better prevent/understand possible complications associated with polymethylmethacrylate extrusion.

Effect of glenoid perforation during total shoulder arthroplasty on glenoid component cement fixation and suprascapular nerve.

Arthritic glenoids are susceptible to vault perforation during total shoulder arthroplasty. We investigated the effects of glenoid perforation and subsequent cement extrusion on the suprascapular nerve and on the glenoid cement infiltration. Total shoulder arthroplasty using three-pegged glenoid components were performed on 10 cadaveric shoulders assigned to two groups (perforation vs. control). In perforation group, the glenoids were reamed eccentrically and intentionally perforated medially through the central peg hole, whereas control group received perpendicular reaming with no perforation. Bone cement was applied to each peg. Spatial relationship between the extruded cement and the suprascapular nerve, and the amount of cement infiltration into the cancellous bone were evaluated. In perforation group, five specimens were perforated anteriorly, and two posteriorly. In the two posteriorly perforated specimens, the suprascapular nerve was in direct contact with extruded cement at the spinoglenoid notch. Perforation group showed significantly less cement infiltration into the cancellous bone than control group (p = 0.008). Glenoid perforation decreases the volume of cement infiltration into the cancellous bone potentially compromising glenoid component fixation. Glenoid perforation tends to occur anteriorly rather than posteriorly in arthritic glenoids; however, if perforation occurs posteriorly, the suprascapular nerve is at immediate risk from the extruded cement.Level of evidence: Basic science study.

Reverse Shoulder Arthroplasty for Failed Proximal Humerus Osteosynthesis With Intramedullary Allograft: A Case Series

Introduction The presence of retained intramedullary fibular allograft presents many challenges during reverse shoulder arthroplasty (RSA), which have been discussed in limited fashion. This case series presents a single-surgeon experience with 6 patients treated with RSA following failed osteosynthesis of proximal humerus fractures using intramedullary allografts. Methods A retrospective review was conducted of RSA patients with a minimum of 2-year follow-up (exception of 1 deceased patient) for failed plate fixation of proximal humerus fractures. Two cohorts were created based on the presence of an intramedullary allograft during the procedure. Patient-reported outcome measures, active range of motion, time to revision, surgical time, complications, and case descriptions were obtained from chart review and radiographic analysis. Results When treating patients with a retained allograft, the surgeon used a guide pin from a cannulated screw set to advance through the graft, and a cannulated drill was used to ream and bypass the allograft, contributing to a 22% increase in surgical time (151 vs 124 min). Intraoperative complications were observed only in the allograft cohort (50%; 3 of 6), including cortical perforation with cement extrusion, humeral loosening, and proximal humerus bone loss. Patients treated with a retained allograft experienced pain relief ( P = .001) but did not gain significant functional improvements. Conclusion RSA for failed proximal humerus fixation with healed intramedullary allograft is associated with increased operative time and intraoperative complications, and patients can mostly expect pain relief. Techniques for humeral canal preparation and stem placement to bypass the allograft are helpful in managing these revisions.

Prevention is Better Than Cure: A Key to Halt Peri-Implantitis

To evaluate and compare the effect of VENT holes in crown at two different places on extrusion of excess cement at crownabutment interface and associated tensile force in cement retained implant restorations- An In-Vitro Study.