Modern Cementing Technique Research Articles

The third-generation modern cementing technique in hip and knee arthroplasty

Implant loosening is the most common reason for revision surgery. Contribution of modern cementing technique to the long-term stability of an implant. Evaluation of the available evidence on modern cementing technique. Modern cementing technique in hip arthroplasty is considered established and leads to better cementing results. In knee arthroplasty, there are also specific recommendations, including intensive cleaning of the bone bed, mixing of bone cement under vacuum and application of bone cement to the implant and the bone. The use of modern cementing technique in hip and knee arthroplasty facilitates cementing, increases safety, and minimizes the risk of mechanical loosening.

Femoral Stem Cementation in Primary Total Hip Arthroplasty.

Femoral stem cementation has undergone considerable investigation since bone cement was first used in arthroplasty, leading to the evolution of modern femoral stem cementation techniques. Although there is a worldwide trend toward the use of cementless components, cemented femoral stems have shown superiority in some studies and have clear indications in specific populations. There is a large evidence base regarding cement properties, preparation, and application techniques that underlie current beliefs and practice, but considerable controversy still exists. Although the cementing process adds technical complexity to total hip arthroplasty, growing evidence supports its use in certain cohorts. As such, it is critical that orthopaedic surgeons and investigators have a thorough understanding of the fundamentals and evidence underlying modern cementation techniques.

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.

CORR Insights®: Does the Risk of Death Within 48 Hours of Hip Hemiarthroplasty Differ Between Patients Treated with Cemented and Cementless Implants? A Meta-analysis of Large, National Registries.

CORR Insights®: Does the Risk of Death Within 48 Hours of Hip Hemiarthroplasty Differ Between Patients Treated with Cemented and Cementless Implants? A Meta-analysis of Large, National Registries.

Femoral Stem Cementation in Hip Arthroplasty: The Know-How of a "Lost" Art.

To describe the (1) indications, (2) preoperative precautions, and (3) stepwise technical details of modern femoral stem cemented fixation. Femoral stem cementation provides excellent implant longevity with a low periprosthetic fracture rate among patients with compromised bone quality or aberrant anatomy. Unfamiliarity with the details of modern cementation techniques among trainees who may lack frequent exposure to cementing femoral stems may preclude them from offering this viable option to suitable patients in later stages of their careers. As such, maximizing benefit from cemented femoral stem fixation among suitable candidates is contingent upon the meticulous use of modern cementation techniques. In addition to proper patient selection, modern cementation techniques emphasize the use of (1) pulsatile lavage of the femoral canal, (2) utilization of epinephrine-soaked swabs, (3) vacuum cement mixing, (4) retrograde cement introduction, (5) cement pressurization, and (6) the use of stem centralizers. Furthermore, identifying and optimizing the preoperative status of at-risk patients with pre-existing cardiopulmonary compromise, in addition to intraoperative vigilance, are essential for mitigating the risk of developing bone cement implantation syndrome. Further research is required to assess the utility of cemented femoral stem fixation among younger patients.

The Use of Cement in Hip Arthroplasty: A Contemporary Perspective.

Notable advances in hip arthroplasty implants and techniques over the past 60 years have yielded excellent survivorship of fully cemented, hybrid, and reverse hybrid total hip replacements as demonstrated in joint registries worldwide. Major advances in noncemented implants have reduced the use of cement, particularly in North America. Noncemented implants predominate today based on procedural efficiency, concern related to thromboembolic risk, and a historic belief that cement was the primary cause of osteolysis and implant loosening. With the decline of cemented techniques, press-fit fixation has become common even in osteoporotic elderly patients. Unfortunately, there is a troubling rise in intraoperative, as well as early and late postoperative periprosthetic fractures associated with the use of noncemented implants. Despite the success of noncemented fixation, an understanding of modern cement techniques and cemented implant designs is useful to mitigate the risk of periprosthetic fractures. Cemented acetabular components can be considered in elderly patients with osteoporotic or pathologic bone. Cemented stems should be considered with abnormal proximal femoral morphology, conversion of failed hip fixation, inflammatory arthritis, patient age over 75 (especially women), osteoporotic bone (Dorr C), and in the treatment of femoral neck fractures.

Paper #2 - Radiographic and Clinical Comparison of Pegged and Keeled Glenoid Components Using Modern Cementing Techniques: Midterm Results of a Prospective Randomized Study

Background: Glenoid component loosening remains a significant issue after anatomic shoulder arthroplasty. Pegged glenoid components have shown better lucency rates than keeled components in the short term, however, mid to long-term results have not fully been determined. We previously reported early outcomes of this randomized, controlled group of patients, with higher glenoid lucency rates in patients with a keeled glenoid. The purpose of this study was to evaluate the radiographic and clinical outcomes of pegged and keeled glenoid components at midterm follow-up.

Influence of Internal Fixation and Cemented Hemiarthroplasty on 1-Year Mortality in Geriatric Hip Fracture Patients

AIM: Results after cemented Hemiarthoplasty (HA) in elderly patients with a femoral neck fracture improved over the last 20 years. We conducted this study in order to evaluate the influence of modern cemented HA compared to IF with a sliding hip screw (SHS) with regard to one year mortality. PATIENTS AND METHODS: 183 patients with a low-energy medial femoral neck fracture (AO/OTA 31-B) either treated with a SHS (n = 67) or cemented HA (n = 116) were included. Follow-up was performed at 6 and 12 months. A multivariate Cox regression analysis including nine confounding variables (age, ASA score, body mass index (BMI), cognitive function, time from admission to surgery, creatinine, c-reactive protein (CRP), 25-hydroxyvitamin D (25(OH)D) was performed. RESULTS: Patients in the HA group were significantly older (p < 0.001) and had more severe comorbidities according to the ASA-Score (p = 0.017). The time interval from admission to surgery (skin incision) was beyond 48h in 6.0% of SHS patients and 17.2% in HA patients (p < 0.001). Despite of detrimental prerequisites for cemented HA, mortality rates at 1 year for HA (23.3%) showed no significant difference (p = 0.58) to IF (19.4%). After correcting for confounding variables mortality risk at one year was significantly higher in patients treated with a SHS (HR = 2.5, 95%CI 1.1-5.7; p = 0.027). CONCLUSION: We conclude that elderly patients with a femoral neck fracture might benefit from cemented HA compared to IF with a SHS in terms of 1-year mortality. New randomised controlled trials considering modern cementing techniques are needed to validate these results.

Influence of Internal Fixation and Cemented Hemiarthroplasty on 1-Year Mortality in Geriatric Hip Fracture Patients

AIM: Results after cemented Hemiarthoplasty (HA) in elderly patients with a femoral neck fracture improved over the last 20 years. We conducted this study in order to evaluate the influence of modern cemented HA compared to IF with a sliding hip screw (SHS) with regard to one year mortality. PATIENTS AND METHODS: 183 patients with a low-energy medial femoral neck fracture (AO/OTA 31-B) either treated with a SHS (n = 67) or cemented HA (n = 116) were included. Follow-up was performed at 6 and 12 months. A multivariate Cox regression analysis including nine confounding variables (age, ASA score, body mass index (BMI), cognitive function, time from admission to surgery, creatinine, c-reactive protein (CRP), 25-hydroxyvitamin D (25(OH)D) was performed. RESULTS: Patients in the HA group were significantly older (p &lt; 0.001) and had more severe comorbidities according to the ASA-Score (p = 0.017). The time interval from admission to surgery (skin incision) was beyond 48h in 6.0% of SHS patients and 17.2% in HA patients (p &lt; 0.001). Despite of detrimental prerequisites for cemented HA, mortality rates at 1 year for HA (23.3%) showed no significant difference (p = 0.58) to IF (19.4%). After correcting for confounding variables mortality risk at one year was significantly higher in patients treated with a SHS (HR = 2.5, 95%CI 1.1-5.7; p = 0.027). CONCLUSION: We conclude that elderly patients with a femoral neck fracture might benefit from cemented HA compared to IF with a SHS in terms of 1-year mortality. New randomised controlled trials considering modern cementing techniques are needed to validate these results.

Thermal Analysis of the Tibial Cement Interface with Modern Cementing Technique.

Background:The major cause of cemented Total Knee Arthroplasty (TKA) failure is aseptic loosening of the tibial component necessitating revision surgery. Recently, multiple techniques have been described to maximize cement penetration depth and density in the proximal tibia during TKA to potentially avoid early loosening. While cement polymerisation is an exothermic reaction, minimal investigation into the proximal tibial thermal safety margin during cement polymerisation has been undertaken. In animal models osseous injury occurs at temperatures greater than 47 °C when applied for one minute. The aim of this study was to investigate the cement bone interface temperatures in TKA using modern tibial cementing techniques with a cadaveric tibial tray model. Methods:Eight adult cadavers were obtained with the proximal tibial surface prepared by a fellowship trained arthroplasty surgeon. Third generation cementation techniques were used and temperatures during cement polymerization on cadaveric knee arthroplasty models were recorded using thermocouples. Results:The results showed that no tibial cement temperature exceeded 44 °C for more than 1 minute. Two of the eight cadaveric tibias recorded maximum temperatures greater than 44 °C for 55 seconds and 33 seconds, just less than the 60 seconds reported to cause thermal injury. Average maximum polymerization temperatures did not correlate with deeper cement penetration or tray material. Maximum mantle temperatures were not statistically different between metal and all polyethylene tibial trays. Conclusion:Our investigation suggests that modern cementing techniques result in maximum mantle temperatures that are less than previously recorded temperatures required to cause thermal osseous injury, although this thermal injury safety margin is quite narrow at an average of 4.95 °C (95% confidence interval ± 4.31).

Benefits of Using Modern Cementing Techniques in the Acetabulum: The Rim Cutter

To compare radiological records of 90 consecutive patients who underwent cemented total hip arthroplasty (THA) with or without use of the Rim Cutter to prepare the acetabulum. The acetabulum of 45 patients was prepared using the Rim Cutter, whereas the device was not used in the other 45 patients. Postoperative radiographs were evaluated using a digital templating system to measure (1) the positions of the operated hips with respect to the normal, contralateral hips (the centre of rotation of the socket, the height of the centre of rotation from the teardrop, and lateralisation of the centre of rotation from the teardrop) and (2) the uniformity and width of the cement mantle in the 3 DeLee Charnley acetabular zones, and the number of radiolucencies in these zones. The study group showed improved radiological parameters and were closer to the anatomic centre of rotation both vertically (1.5 vs. 3.7 mm, p<0.001) and horizontally (1.8 vs. 4.4 mm, p<0.001) and had consistently thicker and more uniform cement mantles (p<0.001). There were 2 radiolucent lines in the control group but none in the study group. The Rim Cutter resulted in more accurate placement of the centre of rotation of a cemented prosthetic socket, and produced a thicker, more congruent cement mantle with fewer radiolucent lines.

Fixation of the glenoid component in total shoulder arthroplasty: What is “modern cementing technique?”

Cemented fixation of the glenoid component is currently considered the gold standard in total shoulder arthroplasty (TSA). This article reviews the original description and currently used techniques for cementing the glenoid component, attempts to clarify the term “modern cementing technique” and provides direction for future research.

Einfluss der Knochendichte und der Zementiertechnik auf die In-vitro-Zementverteilung in der Schulterendoprothetik

Loosening of the glenoid component is one of the major causes of failure in total shoulder arthroplasty. Possible risk factors for loosening of cemented components include an eccentric loading, poor bone quality, inadequate cementing technique and insufficient cement penetration. The application of a modern cementing technique has become an established procedure in total hip arthroplasty. The goal of modern cementing techniques in general is to improve the cement-penetration into the cancellous bone. Modern cementing techniques include the cement vacuum-mixing technique, retrograde filling of the cement under pressurisation and the use of a pulsatile lavage system. The main purpose of this study was to analyse cement penetration into the glenoid bone by using modern cement techniques and to investigate the relationship between the bone mineral density (BMD) and the cement penetration. Furthermore we measured the temperature at the glenoid surface before and after jet-lavage of different patients during total shoulder arthroplasty. It is known that the surrounding temperature of the bone has an effect on the polymerisation of the cement. Data from this experiment provide the temperature setting for the in-vitro study. The glenoid surface temperature was measured in 10 patients with a hand-held non-contact temperature measurement device. The bone mineral density was measured by DEXA. Eight paired cadaver scapulae were allocated (n = 16). Each pair comprised two scapulae from one donor (matched-pair design). Two different glenoid components were used, one with pegs and the other with a keel. The glenoids for the in-vitro study were prepared with the bone compaction technique by the same surgeon in all cases. Pulsatile lavage was used to clean the glenoid of blood and bone fragments. Low viscosity bone cement was applied retrogradely into the glenoid by using a syringe. A constant pressure was applied with a modified force sensor impactor. Micro-computed tomography scans were applied to analyse the cement penetration into the cancellous bone. The mean temperature during the in-vivo arthroplasty of the glenoid was 29.4 °C (27.2-31 °C) before and 26.2 °C (25-27.5 °C) after jet-lavage. The overall peak BMD was 0.59 (range 0.33-0.99) g/cm (2). Mean cement penetration was 107.9 (range 67.6-142.3) mm (2) in the peg group and 128.3 (range 102.6-170.8) mm (2) in the keel group. The thickness of the cement layer varied from 0 to 2.1 mm in the pegged group and from 0 to 2.4 mm in the keeled group. A strong negative correlation between BMD and mean cement penetration was found for the peg group (r (2) = -0.834; p < 0.01) and for the keel group (r (2) = -0.727; p < 0.041). Micro-CT shows an inhomogenous dispersion of the cement into the cancellous bone. Data from the in-vivo temperature measurement indicate that the temperature at the glenohumeral surface under operation differs from the body core temperature and should be considered in further in-vitro studies with human specimens. Bone mineral density is negatively correlated to cement penetration in the glenoid. The application of a modern cementing technique in the glenoid provides sufficient cementing penetration although there is an inhomogenous dispersion of the cement. The findings of this study should be considered in further discussions about cementing technique and cement penetration into the cancellous bone of the glenoid.

Zementiertechnik in der Endoprothetik des Hüftgelenks: eine Übersicht

For decades the cemented anchorage of hip prostheses, especially for elderly patients, is the standard procedure. The cementing technique has turned out to be the determining factor for the survival of the implant. In the last few years developments in this field have been able to further improve the long-term survival. Established components of the modern cementing technique are vacuum-mixed cements, medullary canal plugs, centralising elements und the use of jet-lavages. The design of the cemented shaft depends on the more important surface finish. In the most clinical studies, polished shafts turned out to be slightly superior as compared to shafts with rough surfaces.

Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique

We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt > 5 degrees or subsidence > 5 mm), the presence of radiolucent lines and a Constant score of < 30 as the endpoints. There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of > 30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001). We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement.

Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique

Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique

An experimental comparison of different devices for pulsatile high-pressure lavage and their relevance to cement intrusion into cancellous bone

Some of the systems marketed for pulsatile high-pressure lavage are clearly different in their mechanical pulse characteristics. To take the matter further we set up an experimental in vitro model to determine whether these different lavage systems might produce different cementation results because of their differing pulse characteristics, and whether the systems differed significantly in terms of cement depth penetration. A total of 48 femoral heads were obtained at operation from patients who had undergone endoprosthetic hip replacement. The specimens were subjected to manual rinsing or semiautomatic cleansing procedures with five different pulsatile lavage devices. After the cleansing procedures, polymethylmetacrylate bone cement was intruded into the cancellous bone under standardised conditions. Determination of cement penetration was done by computed tomography using an image processing software. Irrespective of the nature of the lavage system tested, superficial cement penetration, both up to 2 mm and up to 3 mm, was significantly better after pulsatile high-pressure lavage than it was after manual rinsing of the specimens with a bladder syringe (P < 0.001 in each case). Whereas our experimental model did not show any significant differences between the lavage systems as regards the cementation results to a depth of up to 2 mm (P = 0.996), there were significant differences at a target depth of 3 mm (P < 0.05). As compared with manual rinsing, pulsatile high-pressure lavage in vitro makes highly significant improvements in cement penetration into cancellous bone and should be regarded as an indispensable component of modern cementation techniques for endoprosthetic surgery. Up to the present we have not been able to ascertain what influence the different pulse characteristics of a pulsatile lavage system may have on the intended cementation result, whether it is impact force, pulse shape, pulse duration, flow rate or frequency. Appropriate investigations will be necessary.

Shoulder replacement: emerging trends

Purpose of review Total shoulder arthroplasty is a highly effective and predictable treatment for degenerative conditions of the glenohumeral joint. Improving implant survival by limiting complications, such as component loosening, has been the focus of a great deal of recent research. Recent findings Despite advances in component design and fixation, glenoid loosening remains a common indication for revision. Modern cement techniques, convex backing and pegged designs have been shown to improve radiographic results for cemented polyethylene components. Despite the theoretical advantage of permanent biologic fixation, metal-backed glenoid components have not had recent clinical success, and continued research in this area is necessary. Materials such as porous tanatalum may offer improved ingrowth fixation and increased component longevity. Humeral surface replacement is an alternative to traditional stemmed shoulder arthroplasty, and clinical studies are promising. Regional anesthesia is being used safely and effectively in shoulder surgery, and may allow shoulder arthroplasty to be performed on an outpatient basis. Summary The overall complication rate of total shoulder arthroplasty may be decreasing, but issues such as glenoid loosening remain problematic. Advances will aim to improve patient function and implant longevity. This review discusses current trends and areas of recent research in the field of shoulder replacement.

Bone substitution in revision hip replacement

The aim of this retrospective study was to report the preliminary results of femoral peri-prosthetic bone defect reconstruction with a synthetic bone substitute. Twenty-one revisions of the femoral component in 20 patients were evaluated. The mean age at operation was 65.7 years (range, 30 to 79 years). Preoperative femoral deficiencies were rated grade II in 7 cases and grade III in 14 cases according to the SOFCOT classification. None was rated grade IV. Femoral revision was indicated for loosening in 18 hips (including 8 septic cases), femoral osteolysis (1 hip), persistent pain (1 hip) and recurrent dislocation (1 hip). Once the loose prosthesis had been removed, calcium phosphate ceramic (CPC) granules (14 cases) or ceramic granules + cancellous allograft (5 cases) or autograft (2) were firmly impacted in the femoral canal. The stem was standard and always cemented using modern cementing technique. At a mean follow-up of 36 months (range, 14 to 76 months), 90% of the hips were rated good or very good according to the Merle d'Aubigné score. Two diaphyseal femoral fractures occurred and later united. Two hips required re-revision (aseptic loosening; septic recurrence). The absence of radiological osteolysis in 17 cases suggested direct bonding between ceramic granules and bone. Stem subsidence occurred in two cases and was limited (5 and 8 mm). Femoral bone reconstruction using impacted CPC or CPC in conjunction with bone graft in revision hip replacement commonly provided restoration of the bone stock in the short to mid-term. Further long-term studies will be necessary to support this conclusion.

Reconstruction fémorale par céramique de phosphate de calcium macroporeuse impactée au cours des reprises d’arthroplastie de hanche

Purpose of the study Management of bone stock loss remains one of the most challenging problems for revision hip surgery. The aim of this retrospective study was to report the preliminary results of peri-prosthetic femoral defect reconstruction with impacted granules of calcium phosphate ceramic. Material and methods Fourteen hips in 13 patients (3 men and 10 women) were evaluated. Age at surgery ranged from 30 to 79 years (mean 66.1 years). All revised devices had been cemented. Femoral revision was indicated for loosening in eleven hips (including six septic cases), femoral osteolysis (one hip), persistent pain (one hip), and recurrent dislocation (one hip). On the preoperative radiological evaluation, bone defects were assessed as SOFCOT grade II in seven case, and grade III in fourteen. None was rated grade IV. Once the loose prosthesis had been removed, bone graft or ceramic granules (14 cases) were firmly impacted in the femoral canal. The stem was standard and always cemented using modern cementing technique. Results At a mean follow-up of 34 ± 15 months (range 14-76 months), eleven of fourteen hips were rated good or very good according to the Postel-Merle-d’Aubigné score. One diaphyseal femoral fracture occurred and later united. Two hips required re-revision (one aseptic femoral loosening, one septic recurrence). Direct bonding between synthetic graft and bone was observed on standard radiographs in eleven cases. Stem subsidence occurred in two cases and was limited (mean 4.5 mm). Discussion Femoral bone reconstruction using impacted calcium phosphate ceramic in revision hip arthroplasty provided encouraging results in the short to mid term. Femoral stock restoration was achieved in the great majority. No adverse effect related to the use of a synthetic graft was noted. Further long-term evaluation is required before wider application.