Abstract
Background
Cement restrictors are used for maintaining good filling and pressurization of bone cement during hip and knee arthroplasties. The limitations of certain cement restrictors include the inability to accommodate for large medullary canals particularly in revision procedures. We describe a technique using SurgicelTM (Johnson & Johnson) and SPONGOSTAN™ (Johnson & Johnson) (Fig 1) to form a cement restrictor that can accommodate for large canal diameters and provide excellent pressurisation.
Technique
The technique involves the application of SPONGOSTAN™ (Johnson & Johnson) foam onto a SurgicelTM (Johnson & Johnson) mesh which is then rolled onto the SPONGOSTAN™ foam forming a uniform cylindrical structure Figs 2,3. The diameter of the restrictor can be adjusted according to the desired femoral canal diameter through increasing the thickness of the SPONGOSTAN™ (Johnson & Johnson) foam. The restrictor is then inserted into the desired position in the medullary canal where it expands uniformly creating an effective restrictor and bone plug Fig 4. Bone cement is then applied and pressurisation commenced prior to the insertion of the implant Fig5.
SPONGOSTAN™ is an absorbable haemostatic sponge intended for haemostatic use by applying to a bleeding surface. It consists of a sterile, water-insoluble, malleable, porcine gelatin absorbable sponge.
Surgicel ™ is an absorbable hemostatic agent composed of oxidized regenerated cellulose. It is a sterile, absorbable knitted fabric that is flexible and adheres readily to bleeding surfaces. Both products are routinely used for their haemostatic properties in various surgical disciplines.
Discussion
The use of intramedullary plugs in cemented total joint arthroplasty is essential in order to achieve good filling and pressurization in hip and knee arthoplasties, traditionally, a small piece of bone or a cement restrictor may be used to plug the shaft. Distal plugs seal the femoral canal, improve fixation and prevent bone cement from leaking during delivery and pressurization. Plugging the intramedullary canal during total hip arthroplasty increases penetration of cement into cancellous bone proximal to the intramedullary plug.
Numerous plug designs and materials are available ranging from non-resorbable to resorbable. Regardless of design, all restrictors should avoid intramedullary cement leakage and plug migration during cement and stem insertion to ensure adequate intramedullary pressures
In some instances the diameter of the femoral canal is too wide to accommodate a conventional cement restrictor particularly when crossing the femoral isthmus and even more so in revision procedures requiring the implantation of long stemmed cemented components.
The use of the Surgicel-Spongostan haemostatic restrictor overcomes some of the limitations of a standard cement restrictors. These include the ability to bypass a narrow femoral isthmus, accommodate large femoral canals, particularly in revision procedures, and the flexibility of adjusting the restrictor to the desired diameter of the medullary canal and in effect providing a bespoke cement restrictor.
This technique was used successfully in over 300 revision hip and knee procedures with no adverse effects and excellent outcomes.
