Third-generation Cementing Technique Research Articles

Retrograde Cement Extrusion into Femoral Nutrient Vessels Following Uncomplicated Total Hip Arthroplasty

The present concepts in Total Hip Arthroplasty advocate mechanical cement interlock with trabecular bone utilising the third-generation cementing technique. However, the force generated can easily reach peak pressure of 122 kPa to 1500 kPa, leading to extrusion of cement through nutrient foramina into femoral cortex into nutrient vessels, henceforth the retrograde arteriovenogram. A 76 years old lady who premorbid ADLindependent had a fall and sustained a closed right neck of femur fracture. She underwent cemented right total hip arthroplasty. Acetabulum cup of 47mm and femoral stem size 1 was utilized. Femoral canal was prepared and medullary cavity plug inserted before retrograde cement was introduced using the cementing gun. Intraoperative no complications were noted. This case has been followed up to a year with no adverse effect. The post-operative radiograph demonstrated a linear radio-opacity communicating with the posterior aspect of the femoral shaft which continues proximally and medially for approximately 10cm. Its uniformity in shape and position corresponds to the vascular supply of proximal femur. In Farouk et al cadaveric study, nutrient vessel arises in 166 ± 10 mm from the greater trochanter and is a branch of the second perforating artery from the deep femoral artery. Knight et al infer that retrograde cement extrusion occurs in female patients with small stature and small endosteal canal. Cement extrusion unlikely will influence the long haul survival of prosthesis as shown in the radiograph that cement is well pressurized to interlock with the endosteal bone. Moreover, because of extensive anastomoses of perforating branches of the deep femoral artery, segmental obliteration of nutrient artery alone is unlikely to lead to vascularity issues. Cement extrusion into the nutrient foramen is a vital differential in presence of posterior medial cement in the diaphysis of the femur following total hip replacement. This is to differentiate from extra osseous extrusions due to the iatrogenic breach of the femoral cortex suggesting periprosthetic fracture which affects the long term survival of prosthesis.

Medium-term follow-up of 92 femoral component revisions using a third-generation cementing technique

Background and purpose — Very little has been published on the outcome of femoral cemented revisions using a third-generation cementing technique. We report the medium-term outcome of a consecutive series of patients treated in this way.Patients and methods — This study included 92 consecutive cemented femoral revisions performed in our department with a third-generation cementing technique and without instrumented bone impaction grafting between 1996 and 2007. The average age of the patients at revision was 66 (25–92) years. None of the patients were lost to follow-up. At review in December 2013, 55 patients were still alive and had a non-re-revised femoral revision component in situ after a mean follow-up of 11 (5–17) years.Results — The mean preoperative Harris hip score was 50, and improved to 73 at final follow-up. 2 patients died shortly after the revision surgery. 1 stem was re-revised for aseptic loosening; this was also the only case with radiolucent lines in all 7 Gruen zones. A femoral reoperation was performed in 19 hips during follow-up, and in 14 of these 19 reoperations the femoral component was re-revised. Survivorship at 10 years, with femoral re-revision for any reason as the endpoint, was 86% (95% CI: 77–92). However, excluding 8 patients with reinfections after septic index revisions and 1 with hematogenous spread of infection from the survival analysis, the adjusted survival for re-revision for any reason at 10 years was 92% (95% CI: 83–96). With re-revision for aseptic loosening as endpoint, the survival at 10 years was 99% (CI: 90–100).Interpretation — Femoral component revision with a third-generation cemented stem results in acceptable survival after medium-term follow-up. We recommend the use of this technique in femoral revisions with limited loss of bone stock.

Pressurisation leads to better cement penetration into the glenoid bone

The aim of this study was to compare a third-generation cementing procedure for glenoid components with a new technique for cement pressurisation. In 20 pairs of scapulae, 20keeled and 20 pegged glenoid components were implanted using either a third-generation cementing technique (group 1) or a new pressuriser (group 2). Cement penetration was measured by three-dimensional (3D) analysis of micro-CT scans. The mean 3D depth of penetration of the cement was significantly greater in group 2 (p < 0.001). The mean thickness of the cement mantle for keeled glenoids was 2.50mm (2.0 to 3.3) in group 1 and 5.18 mm (4.4to 6.1) in group 2, and for pegged glenoids it was 1.72mm (0.9 to 2.3) in group 1 and 5.63mm (3.6 to 6.4) in group 2. A cement mantle < 2 mm was detected less frequently in group 2 (p < 0.001). Using the cement pressuriser the proportion of cement mantles < 2 mm was significantly reduced compared with the third-generation cementing technique.

No benefit of a proximal stem centralizer in cementing of a femoral prosthesis in human cadavers

Background and purpose A proximal stem centralizer may be beneficial regarding cementing pressures, cement penetration, and stem alignment. We measured these parameters when cementing a mat-surfaced femoral component with and without the use of a proximal stem centralizer.Material and methods 8 femoral prostheses with proximal centralizers and 8 femoral prostheses without proximal centralizers were cemented according to third-generation cementing technique in 8 pairs of embalmed cadaveric femora. We recorded intramedullary pressures (peak levels, the area under the pressure curves and mean pressure) with 6 pressure transducers during stem cementation. Computer tomographic scanning of specimens was performed to evaluate stem alignment after surgery. Thickness of the cement mantle, cement penetration, and stem centralization at the metaphyseal part of the femur were measured on cross sections using stereology.Results There were no statistically significant differences in measured pressure and cement penetration values between the groups. There was similar cement distribution around the stems; however, in using a proximal centralizer, the cement mantle tended to be thinner laterally. Moreover, we found a larger variation in stem alignment on lateral projection in the proximal centralizer group.Interpretation No benefits regarding intramedullary pressures and cement penetration were obtained from cementation of a straight stem with a proximal stem centralizer. However, there was an increased risk of inferior stem positioning in the reamed medullary cavity using the centralizing device.

Intraoperative monitoring for safety of total hip arthroplasty using third-generation cementing technique

Background Controversies on the safety of the cement application between cemented and uncemented total hip arthroplasty (THA) have been existing for decades. The purpose of this study was to observe the changes in mean arterial pressure (MAP), heart rate (HR) and oxygen pressure (PaO2) during cemented THA, and to evaluate the intraoperative safety of using the third-generation cementing technique and investigate whether the intraoperative risk is higher in acute femoral neck fracture patients than non-traumatic patients. Methods Forty-two patients who underwent cemented THA between November 2005 and September 2007 were prospectively included in this study. The third-generation cementing technique as vacuum mixing and pulsatile lavage was used strictly. The MAP and HR were monitored and documented during each operation. Blood gas analysis was performed at exposure, cup implantation, stem implantation and wound closure. MAP, HR and PaO2 were compared between pre- and post-cement application. Comparisons of MAP, HR and PaO2 between patients with acute femoral neck fracture and non-traumatic patiens were performed as well. Results No intraoperative cardiopulmonary complication occurred in these cases. No obvious changes were observed in MAP, HR and PaO2 after cement application. There was no significant difference in MAP, HR and PaO2 between acute femoral fracture patients (18 patients) and non-traumatic patients (24 patients). Conclusions The results of this study suggested that the invasive blood pressure monitoring and blood gas analysis are essential for patients undergoing cemented THA, especially for patients with femoral neck fracture. The third-generation cementing technique is safe to use in THA.

Cementless Femoral Prostheses Cost More to Implant than Cemented Femoral Prostheses

Prosthetic cost contributes greatly to the overall expense of THA. A key question, therefore, in the selection of implant technique is whether any price difference exists between a cementless and a cemented femoral prosthesis. We evaluated the price difference between the most commonly used cemented and cementless femoral stems at three high-volume academic medical centers. Each hospital's costs for prostheses from the manufacturers were recorded. The average cost of implanting a cementless femoral prosthesis was $296 more than the average cost of implanting a cemented femoral stem, even with the additional expense of two batches of bone cement and the accessories commonly used to achieve a third-generation cementing technique. The price difference was less variable if the cost of the prostheses from only the primary implant supplier for each institution was considered. As the number of THAs performed per year continues to escalate, implantation of a cemented femoral component remains an attractive method of fixation from an economic standpoint. Level III, economic and decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.

Modes of periacetabular load transfer to cortical and cancellous bone after cemented versus uncemented total hip arthroplasty: A prospective study using computed tomography‐assisted osteodensitometry

Stress-shielding and periprosthetic bone loss after total hip arthroplasty (THA) may be clinically relevant for high-demand patients. Analysis of cortical and cancellous bone density (BD) changes in vivo after THA is of interest to basic science researchers and joint reconstruction surgeons. An insufficient periprosthetic bone stock may predispose to migration, early mechanical failure, and major problems in revision surgery. We used computed tomography (CT)-assisted osteodensitometry in two prospectively analyzed cohorts after cemented (n = 21) versus noncemented (n = 23) cup fixation. Periacetabular BD (mgCaHa/mL) was determined in five CT scans cranial and five CT scans at the level of the cup 10 days and 26 months postoperatively. For press-fit cups BD decreased significantly in all CT cans except in four out of the five scans of cortical bone cranial to the cup. The decrease was highest for cancellous bone ventral to the cup (-45 to -53%). After cemented cup fixation, significant cortical BD decrease was seen ventral to the cup (-11 to -20%). Cancellous BD decrased only ventral (-21 to -31%) and in two scans cranial (-11 and -12%) to the cup. The modes of load transfer between cemented and uncemented cups differ fundamentally. Cemented cups especially prevent the loss of cancellous bone of the acetabulum while also cortical BD loss was significantly lower in most CT scans surrounding the cemented cup compared to the press-fit component. Long-term results are required to prove whether third-generation cementing technique protects periprosthetic BD and thereby improve implant survival.

Long-term survivorship of the Charnley Elite Plus femoral component in young patients

We studied prospectively the long-term results of the Charnley Elite-Plus femoral stem in 184 consecutive young patients (194 hips). There were 130 men and 54 women with a mean age of 49.1 years (21 to 60). The predominant diagnosis was osteonecrosis of the femoral head (63.6%, 117 patients). Clinical and radiological evaluation was undertaken at each follow-up. The mean follow-up was 11.2 years (10 to 12). The mean pre-operative Harris hip score was 43.4 (12 to 49) which improved to 91 (59 to 100) at the final follow-up. The survival of the femoral stem at 12 years was 99% with revision as the end-point. The mean annual linear wear of the polyethylene liner was 0.17 mm (0.13 to 0.22). The prevalence of acetabular osteolysis was 10.8% (21 hips) and osteolysis of the calcar femorale 12.9% (25 hips). A third-generation cementing technique, accurate alignment of the stem and the use of a 22 mm zirconia head were important factors in the prevention of aseptic loosening of the Elite Plus femoral stem in these high-risk young patients.

Uncompromised quality of the cement mantle in Exeter femoral components implanted through a minimally-invasive direct anterior approach

A complete cement mantle is important for the longevity of a total hip replacement. In the minimally-invasive direct anterior approach used at the Innsbruck University hospital, the femoral component has to be inserted into the femoral canal by an angulated movement. In a cadaver study, the quality and the extent of the cement mantle surrounding 13 Exeter femoral components implanted straight through a standard anterolateral transgluteal approach were compared with those of 13 similar femoral components implanted in an angulated fashion through a direct anterior approach. A third-generation cementing technique was used. The inner and outer contours of the cement mantles was traced from CT scans and the thickness and cross-sectional area determined. In no case was the cement mantle incomplete. The total mean thickness of the cement mantle was 3.62 mm (95% confidence interval 3.59 to 3.65). The mean thickness in the group using the minimally-invasive approach was 0.16 mm less than that in the anterolateral group. The distribution of the thickness was similar in the two groups. The mean thickness was less on the anteromedial and anterolateral aspect than on the posterior aspect of the femur. There is no evidence that the angulated introduction of Exeter femoral components in the direct anterior approach in cadavers compromises the quality, extent or thickness of the cement mantle.

The effectiveness of the proximal femoral stem centraliser on the stem alignment in total hip replacement

We studied a new polymethylmethacrylate proximal femoral centraliser designed for use along with the distal femoral centraliser. Using cadaver femora we conducted an in vitro study to measure the influence of the proximal centraliser on the cement mantle and femoral stem alignment in a total hip replacement (THR). The cadaver femora were randomised into two groups. The Royal National Orthopaedic Hospital (RNOH) femoral stems were inserted to each femur using third-generation cementing technique .The first group was inserted using proximal and distal centralisers. The second group was inserted using distal centralisers only. All the hip specimens were X-rayed using high-tech scanner and computer software. The stem alignment and cement mantle were measured. We concluded that the proximal femoral centraliser improved the cement mantle distribution and femoral stem alignment in THR. This improvement will reflect on the long-term survival of the THR. We also showed an excellent and accurate way of measuring the femoral stem alignment in THR.

Revision total hip arthroplasty using third-generation cementing technique

A total of 83 consecutive first-revision total hip arthroplasties were performed in 83 patients using pressurized vacuum-mixed cement, a third-generation cementing technique. At a median follow-up of 3.6 years (range, 1.5-6.3 years), the overall failure rates (radiographic loosening, re-revision, or both) were 39% for the femoral components and 30% for the acetabular components. With definite radiographic loosening as an endpoint, the cement-bone interface achieved was the only significant factor to predict stem durability, with an adjusted odds ratio of 1.8 (95% confidence interval, 1.1-3.0). On the acetabular side, bone stock was the only significant factor, with an adjusted odds ratio of 5.3 (95% confidence interval, 4.0-27.7). In this retrospective cohort study, femoral cement pressurization per se did not appear to improve the results over those of other studies using second-generation techniques.

The femoral component in total hip arthroplasty. Six to eight-year follow-up of one hundred consecutive patients after use of a third-generation cementing technique.

One hundred consecutive patients had a primary unilateral total hip arthroplasty with use of a single design of the femoral component (Harris Precoat), inserted with a so-called third-generation cementing technique, between July 1985 and June 1987. There were seventy-four women and twenty-six men. The mean age at the time of the operation was seventy-one years (range, forty-one to ninety-two years) and the mean weight was seventy kilograms (range, forty-eight to 105 kilograms). Eleven of the 100 patients died during the follow-up period, all with the implant in place. Of the eighty-nine surviving patients, one had a revision arthroplasty for aseptic loosening. The mean duration of clinical follow-up for the remaining eighty-eight patients was seven years (range, six to eight years). The mean Harris hip score at the latest follow-up evaluation was 91 points (range, 68 to 97 points). Of the eighty-eight patients, eighty-five (97 percent) had a good or excellent result. Radiographic follow-up was performed for eighty-one patients; none had evidence of loosening of the stem, and five (6 percent) had endosteal cavitation but were asymptomatic. The rate of failure (loosening or revision) of the femoral component in the entire series was 1 per cent (one hip). The low rate of failure and the maintenance of good and excellent clinical and radiographic results during this period of follow-up are consistent with reports from other institutions. This strengthens the argument to retain or widen the existing indications for the insertion of a femoral stem with cement in primary total hip arthroplasty.