Aims. Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA), and has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA. Methods. A UK-based, three-round, online modified Delphi Expert Consensus Study was completed focusing on cementation technique in TKA. Experts were identified as having a minimum of five years’ consultant experience in the NHS and fulfilling any one of the following criteria: a ‘high volume’ knee arthroplasty practice (> 150 TKAs per annum) as identified from the National joint Registry of England, Wales, Northern Ireland and the Isle of Man; a senior author of at least five peer reviewed articles related to TKA in the previous five years; a surgeon who is named trainer for a post-certificate of comletion of training fellowship in TKA. Results. In total, 81 experts (round 1) and 80 experts (round 2 and 3) completed the Delphi Study. Four domains with a total of 24 statements were identified. 100% consensus was reached within the cement preparation, pressurization, and cement curing domains. 90% consensus was reached within the cement application domain. Consensus was not reached with only one statement regarding the handling of cement during initial application to the tibial and/or femoral bone surfaces. Conclusion. The Cementing Techniques In Knee Surgery (CeTIKS) Delphi consensus study presents comprehensive recommendations on the optimal technique for component cementing in TKA. Expert opinion has a place in the hierarchy of evidence and, until better evidence is available these recommendations should be considered when cementing a TKA. Cite this article: Bone Jt Open 2023;4(9):682–688

The cement in cement technique for revision total hip arthroplasty (THA) has shown good results in selected cases. However, results of its use in the revision of hemiarthroplasty to THA has not been previously reported. Between May 1994 and May 2007 28 (20 Thompson's and 8 Exeter bipolar) hip hemiarthroplasties were revised to THA in 28 patients using the cement in cement technique. All had an Exeter stem inserted at the time of revision. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford. Hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of hemiarthroplasty revision was 80 (35 to 93) years. The reason for revision was acetabular erosion in 12 (43%), recurrent dislocation in eight (29%), aseptic stem loosening in four (14%), periprosthetic fracture in two (7%) and infection in a further two (7%) patients. No patient has been lost to follow up. Three patients died within three months of surgery. The mean follow up of the remainder was 50 (16 to 119) months. Survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Three cases (11%) have since undergone further revision, one for recurrent dislocation, one for infection, and one for periprosthetic fracture. The cement in cement technique can be successfully applied to revision of hip hemiarthroplasty to THA. It has a number of advantages in this elderly population including minimising bone loss, blood loss and operative time

The cement in cement technique for revision total hip arthroplasty (THA) has shown good results in selected cases. However results of its use in the revision of hemiarthroplasty to THA has not been previously reported. Between May 1994 and May 2007 28 (20 Thompson’s and 8 Exeter bipolar) hip hemiarthroplasties were revised to THA in 28 patients using the cement in cement technique. All had an Exeter stem inserted at the time of revision. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of hemiarthroplasty revision was 80 (35 to 93) years. The reason for revision was acetabular erosion in 12 (43%), recurrent dislocation in 8 (29%), aseptic loosening in 4 (14%), periprosthetic fracture in 2 (7%) and infection in 2 (7%) patients. No patient has been lost to follow up. 3 patients died within 3 months of surgery. The mean follow up of the remainder was 50 (16 to 119) months. Survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. 3 cases (11%) have since undergone further revision, 1 for recurrent dislocation, 1 for infection, and 1 for periprosthetic fracture. The cement in cement technique can be successfully applied to revision of hip hemiarthroplasty to THA. It has a number of advantages in this elderly population including minimizing bone loss, blood loss and operative time

Study Aims The purpose of this study is to determine whether the cement mantle produced when a suction cement technique is used leads improved radiological results in the medium term. Methods 74 patients who had a cemented total knee replacement were prospectively studied. In 51 patients the cement was applied in a standard fashion. In 23 patients an intraosseous cannula was used to apply suction within the bone to improve cement penetration. The cannula was inserted into the medial femoral condyle and the medial tibial plateau prior to the bone preparation to vent both bones. Suction is applied to help dry the cancellous surface and draw the cement into the bone. The radiological appearance of the tibial components were prospectively examined to for the appearance of bone lysis. Conclusion This study shows that this technique produces superior radiological appearances in the medium term, which may lead to longer implant survival. A previously published study has shown that if total knee replacement is performed without a tourniquet but using the suction cement technique an excellent cement mantle can reliably be produced

To evaluate the results critically of cemented total hip arthroplasty using a fourth generation cement technique and polished femoral stem, a prospective study was performed in patients under 50 years of age who underwent primary total hip arthroplasty. 55 patients (64 hips) were enrolled in the study (43 were male and 12 were female). Average age of patients was 43.4 years (21–50 years). Elite plus stems (DePuy, Leeds, UK) were cemented and cementless Duraloc cups (DePuy, Warsaw, IN.) were implanted in all hips. 22 mm zirconia femoral head (DePuy, Leeds UK) was used in all hips. All surgeries were performed by one surgeon (YHK). The diagnosis was osteonecrosis (43 hips or 67%), osteoarthritis (5 hips or 4%), O.A. 2° to childhood T.B. or pyogenic arthritis (4 hips or 6%), R.A, (3 hips or 5%), DDH (2 hips or 3%) and others (7 hips or 11%). The average F.U. was 7.2 years (6–8 years). The 4th generation cement technique was utilized including: medullary plug, pulsatile lavage, vaccum mixing of Simplex P cement; cement gun, distal centralizer and proximal rubber seal to pressurize cement. Thigh pain was evaluated using a visual analog scale (10 points). Clinical (Harris hip score) and x-ray follow-up was performed at 6 weeks, 3 months, 6 months, 1 year and then annually. Cementing technique was graded. Abductor moment arm, femoral offset, neck and limb length, center of rotation of hips, cup angle and anteversion were measured in all hips. Linear and volumetric wear were measured by software program. Osteolysis was identified. There was no aseptic loosening or subsidence of components. One hip was revised due to late infection. Incidence of thigh pain was 11% (7 hips). All thigh pain disappeared at 1 year postoperatively. Preoperative Harris hip score was 47.2 (7–67) points and 92.2 (81–100) points at the final F.U. Femoral cementing was classified as grade A in 50 hips (78%), grade B in 6 hips (9%), and grade C1 in 8 hips (13%). There was no cases in grades C2 and D. All bones had type A femoral bone. The average linear wear and annual rate were 1.25 and 0.21 mm, respectively. The average volumetric wear was 473.48 mm3. There was statistically significant relationship between the liner wear, age (under 40), male patient, and the cup angle. Yet there was no statistical relationship between the wear and Dx., wt., hip score, R-O-M, anteversion, anbductor moment arm, femoral offset, neck and limb length and center of rotation of hip. Osteolysis was identified in zone 7A in 6 hips (9%). No hip had distal osteolysis. Advanced cementing technique, polished improved stem design, strong trabecular bone, and utilizing a smaller head and thick polys greatly improved the mid-term survival of the implants in these young patients. Good cementing technique eliminated distal osteolysis and markedly reduced the proximal osteolysis. Yet high linear and volumetric wear of polyethylene liner remains to be a challenging problem

Aim: The purpose of this study was to report our experience mid to long-term results of hybrid cement fixation in revision total knee arthroplasty. Methods: Patients who underwent revision total knee arthroplasty using a hybrid cement technique (press-fit diaphyseal fixation and cemented metaphyseal fixation) with a titanium fluted revision knee implant were reviewed. There were 127 patients. Mean age at surgery was 71 years (range 41–94 years). There were 56 males and 71 females. Mean follow-up was 5 years (range, 2–12 years). A Kaplan-Meier survivorship analysis using an end-point of revision surgery or radiographic loosening was employed to determine probability of survival at 5 and 10 years. Results: 127 patients (135 knees), 31 patients (36 knees) died and 2 patients (2 knees) were lost to follow-up. Six patients (six knees) were revised at a mean of 3.5 years (range 1–8 yrs). Of the 6 revisions, two were for re-infection, two were for (MCL) instability, and two were for aseptic loosening. Mean Knee Society clinical and functional scores were 86 and 55 points, respectively. The mean range of motion was 108 degrees. End of stem pain was not reported in this group of patients. Kaplan-Meier survivorship analysis revealed a probability of survival free of revision for aseptic loosening of 98% at 12 years. Discussion: The results of this study suggest that the use of a hybrid cement technique in revision knee arthroplasty can provide good mid to long-term results. Radiographic analysis has shown continued satisfactory appearances regardless of constraint, stem size and augments. Our experience has shown that the survivorship of a hybrid fixation technique for revision knee arthroplasty is comparable to reported long-term survivorship of cemented revision knee arthroplasty

Purpose. Glenoid component loosening is a common reason for failed total shoulder arthroplasty. Multiple factors have been suggested as causes for component loosening that may be related to cement technique. The purpose of the study was to compare the load transfer across a polyethylene glenoid bone construct with two different cementing techniques. Method. Eight cadaveric specimens underwent polyethylene glenoid component implantation. Four had cement around the pegs only (CPEG) and four had cement across the entire back (CBACK) of the implant including around the pegs. Step loading was performed with a pneumatic actuator and a non-conforming humeral head construct capable of applying loads at various angles. Strain gauges were placed at the superior and inferior poles of the glenoid and position trackers were applied to the superior and inferior aspects polyethylene component. Micro CT data were obtained before and after the loading protocol. Results. During compressive loading, greater tension was recorded with the CBACK technique than with the CPEG technique. Compression was recorded superiorly when load was applied at 30 degrees while tension was recorded inferiorly. Greater displacement occurred with the CPEG group. Failure as defined on micro CT occurred more consistently with the CBACK technique than with the CPEG technique. Conclusion. Tension measurements and upward deflection of the polyethylene with compressive loading at lower angles was unexpected. Early failure of fully cemented glenoids may be due to the fragility of the cement mantle around the periphery of the implant. Tension at the bone cement interface and early cement fracture are unfavorable and this may be a mechanism of implant loosening

Aims. Highly polished stems with force-closed design have shown satisfactory clinical results despite being related to relatively high early migration. It has been suggested that the minimal thickness of cement mantles surrounding the femoral stem should be 2 mm to 4 mm to avoid aseptic loosening. The line-to-line cementing technique of the femoral stem, designed to achieve stem press-fit, challenges this opinion. We compared the migration of a highly polished stem with force-closed design by standard and line-to-line cementing to investigate whether differences in early migration of the stems occur in a clinical study. Methods. In this single-blind, randomized controlled, clinical radiostereometric analysis (RSA) study, the migration pattern of the cemented Corail hip stem was compared between line-to-line and standard cementing in 48 arthroplasties. The primary outcome measure was femoral stem migration in terms of rotation and translation around and along with the X-, Y-, and Z- axes measured using model-based RSA at three, 12, and 24 months. A linear mixed-effects model was used for statistical analysis. Results. Results from mixed model analyses revealed a lower mean retroversion for line-to-line (0.72° (95% confidence interval (CI) 0.38° to 1.07°; p < 0.001), but no significant differences in subsidence between the techniques (-0.15 mm (95% CI -0.53 to 0.227; p = 0.429) at 24 months. Radiolucent lines measuring < 2 mm wide were found in three and five arthroplasties cemented by the standard and line-to-line method, respectively. Conclusion. The cemented Corail stem with a force-closed design seems to settle earlier and better with the line-to-line cementing method, although for subsidence the difference was not significant. However, the lower rate of migration into retroversion may reduce the wear and cement deformation, contributing to good long-term fixation and implant survival. Cite this article: Bone Joint J 2022;104-B(1):19–26

Aims. The main aims were to identify risk factors predictive of a radiolucent line (RLL) around the acetabular component with an interface bioactive bone cement (IBBC) technique in the first year after THA, and evaluate whether these risk factors influence the development of RLLs at five and ten years after THA. Methods. A retrospective review was undertaken of 980 primary cemented THAs in 876 patients using cemented acetabular components with the IBBC technique. The outcome variable was any RLLs that could be observed around the acetabular component at the first year after THA. Univariate analyses with univariate logistic regression and multivariate analyses with exact logistic regression were performed to identify risk factors for any RLLs based on radiological classification of hip osteoarthritis. Results. RLLs were detected in 27.2% of patients one year postoperatively. In multivariate regression analysis controlling for confounders, atrophic osteoarthritis (odds ratio (OR) 2.17 (95% confidence interval (CI), 1.04 to 4.49); p = 0.038) and 26 mm (OR 3.23 (95% CI 1.85 to 5.66); p < 0.001) or 28 mm head diameter (OR 3.64 (95% CI 2.07 to 6.41); p < 0.001) had a significantly greater risk for any RLLs one year after surgery. Structural bone graft (OR 0.19 (95% CI 0.13 to 0.29) p < 0.001) and location of the hip centre within the true acetabular region (OR 0.15 (95% CI 0.09 to 0.24); p < 0.001) were significantly less prognostic. Improvement of the cement-bone interface including complete disappearance and poorly defined RLLs was identified in 15.1% of patients. Kaplan-Meier survival analysis for the acetabular component at ten years with revision of the acetabular component for aseptic loosening as the end point was 100.0% with a RLL and 99.1% without a RLL (95% CI 97.9 to 100). With revision of the acetabular component for any reason as the end point, the survival rate was 99.2% with a RLL (95% CI 97.6 to 100) and 96.5% without a RLL (95% CI 93.4 to 99.7). Conclusion. This study demonstrates that acetabular bone quality, head diameter, structural bone graft, and hip centre position may influence the presence of the any RLL. Cite this article: Bone Joint Open 2021;2(5):278–292

Purpose: Cement implantation syndrome characterized by hypotension, hypoxemia, cardiac arrhythmia or arrest has been reported in the literature. Pulmonary embolization is thought to be the main reason. In our institute, however, we have not experienced major hypotension during THA. To improve longevity of THA, interface bioactive bone cement technique combined with modern cementing technique has been used in our institute. Main principle of this technique is smearing hydroxyapatite granules on the dry bony surface followed by cement pressurization. The purpose of the present study was to monitor blood pressure soon after cementing. Method: The present study includes 91 cases of primary THA with an average age at operation of 64 years old (ranging 35 to 85). Under general anesthesia, both components were cemented using antero-lateral approach. Systolic arterial blood pressure was monitored until 5 minutes with 1 minute interval. The maximum regulation (MR%) was calculated as (maximum change blood pressure – blood pressure before cement insertion) divided by blood pressure before cement insertion. Results: No major complications such as cardiac arrest were observed. In most of the cases, blood pressure increased until 4 minutes for the acetabular side and 2 minutes for the femoral side, and then returned to the blood pressure before cement insertion gradually. In the acetabular side, MR% was 10±13 (−19–40)%. In 52 joints (57.1%), MR% was between 10 to 40 %. In the femoral side, MR% was 5±12 (−20 to 31)%. In 32 joints (35.2%), MR% was between 10 to 31 %. Conclusion: In the present study, major hypotension was not observed. Blood pressure increases if left ventricle reacts to the pulmonary hypertension caused by micro-embolization. If major pulmonary embolization occurs, blood pressure decrease because left ventricle can not compensate for major pulmonary hypertension caused by mayor pulmonary embolization. By good cementing technique which includes washing out debris or fat and obtaining dry bony surface just before cementing, blood pressure soon after cementing was increased

Background. Cement implantation syndrome characterized by hypotension, hypoxemia, cardiac arrhythmia or arrest has been reported in the literature. The purpose of the present study was to monitor blood pressure soon after cementing. Methods. The present study includes 178 cases 204 joints of primary THA with an average age at operation of 64.5 years old (ranging 35 to 89). Under general anesthesia, both components were cemented using antero-lateral approach. Systolic arterial blood pressure during cementing acetabular and femoral components was monitored until 5 minutes with 1 minute interval. The maximum regulation ratio (MRR) was calculated as (maximum change blood pressure – blood pressure before cement insertion) divided by blood pressure before cement insertion. Results. No major complications such as cardiac arrest were observed. In most of the cases, blood pressure increased until 4 minutes for the acetabular side and 2 minutes for the femoral side, and then returned to the blood pressure before cement insertion gradually. In the acetabular side, average MRR was 11.2% (SD, 15.9; range, −26 to 80). Ｉn the femoral side, MRR was 6.4% (SD, 14.9; range, −31 to 65). There was statistical correlation between categories of MRR in the acetabular side and age at operation, the status of bleeding control of the acetabular side. When the bleeding control was judged as complete, blood pressure showed less tendency to decrease. When the bleeding control was judged as good, blood pressure showed more tendency to decrease. Conclusion. In the present study, major hypotension was not observed. Using third generation and IBBC cementing technique, when the bleeding control was judged as complete in the acetabular side, blood pressure showed less tendency to decrease

Improved cement technique by interposing less than two layers of hydroxyapatite (HA) granules between bone and bone cement at the cementing (Interface Bio-active Bone Cement : IBBC) have been performed in total knee arthroplasty (TKA) since 1987. We performed IBBC technique in 153 knees (130 patients) in TKA from 1987 to 1993. One hundred and forty knees (120 patients) could be followed up clinically and radiologically. Follow up rate was 91.5%. A mean follow-up period was 9.5 years (6 to 13 years) after surgery. As a control, clinical results of TKA with conventional cementing (Non-IBBC) which were operated in 44 knees (44 patients) in 1986 were used. In IBBC cases, radiolucent lines on the tibial components were seen 7.1%, 2.9%, 1.4%, 3.6%, 0%, 0% and 0% at Zone ‡T to ‡Z of the anteroposterior view, while in Non-IBBC cases, 40.9%, 13.6%, 9.1%, 27.3%, 11.4%, 4.5% and 13.6% at Zone ‡T to ‡Z, respectively. In IBBC cases peri-prosthetic osteolysis of the tibial components were seen in three knees (2.1%), while 29.5% in Non-IBBC cases. Aseptic loosening of the tibial component was only one case (0.7%) in IBBC cases, while 9.1% in Non-IBBC cases. In IBBC, bone cement bound to HA mechanically immediately after surgery and HA granules bound to the bone physicochemically after bone ingrowth into the spaces around the HA granules. In Non-IBBC, spaces will appear between bone and bone cement due to osteoporosis and/or atrophy after long years. However, in IBBC, bone and bone cement will contact by interposing HA forever due to osteoconductive effect of HA. In conclusion, the IBBC has significantly reduced the incidence of radiolucent lines and periprosthetic osteolysis in TKAs. IBBC is a method combining the advantage of cementless HA coating and bone cement

INTRODUCTION. we have previously reported that bone preparation is quite precise and accurate relative to a preoperative plan when using a robotic arm assisted technique for UKA. However, in that same study, we found a large variation between intended and final tibial implant position, presumably occuring during cement curing. In this study, we reviewed a subsequent cohort of patients in which the tibial and femoral components were cemented individually with ongoing evaluation of tibial component position during cement curing. METHODS AND MATERIALS. Group 1 comprised the simultaneous cementing techniquegroup of patients, previously reported on, although their x-rays were re-analyzed. Group 2 consisted of the individual cementing technique cohort. All implants were identical, specifically a flat, inlay all-polyethylene tibial component. Postoperative x-rays from each cohort of patients were evaluated using image analysis software. Statistical evaluation was performed. RESULTS. In Group 1, average bone preparation was 5.13 + 2.70 degrees of varus and 7.40 + 2.59 degrees of posterior slope. Final implant position was 3.56 + 1.93 degrees of varus and 5.19 + 3.37 degrees of slope. The variance from intended position was 2.31 + 1.74 degrees of varus and 3.80 + 2.90 degrees of slope. For Group 2, average bone preparation was 5.26 + 3.70 degrees of varus and 5.49+ 2.39 degrees of posterior slope. Final implant position was 6.58 + 3.40 degrees of varus and 6.11 + 2.39 degrees of slope. The variance from intended position was 1.82 + 1.42 degrees of varus and 1.39 + 1.48 degrees of slope. ANOVA revealed no differences between groups regarding bone prep in the coronal plane, final implant slope, or variation from intended coronal position. However, bone prep in the sagittal plane showed statistically significant more slope for Group 1 (p = 0.03), increased slope in Group 2 (p=0.004), and greater variation from intended sagital position for Group 1. CONCLUSIONS. Independent cementing of implants showed decreased variation in final tibial component position. However, some implants showed up to 6 degrees of malposition from the intended position. We believe this to be a shortcoming of the inlay style of tibial component for UKA, which even cannot be overcome with the precision and accuracy of a robotic arm assistant

We have used Interface Bioactive Bone Cement (IBBC) in all cases of total joint arthroplasties since 1987. The method is improved cement technique by interposing less than two layers of hydroxyapatite (HA) granules between bone and the polymethylmethacrylate (PMMA) bone cement. We report one patient who underwent revision surgery after total knee arthroplasty (TKA) using IBBC. The patient is a woman aged 70 years at the time of revision surgery. Right TKA was performed with the diagnosis of rheumatoid arthritis. An alumina ceramic total knee prosthesis was inserted using IBBC. Pain and walking ability were once improved after the primary TKA. However, the gait disturbance recurred after the patient fell on the ground. Radiographic findings showed severe genu varum, but neither radiolucent lines around the components nor migration of the components were seen. This was revised with semiconstrained prosthesis for the purpose of improving lateral instability at 31 months after the primary TKA. Avulsion of fibular attachment of collateral ligament was seen at the time of the revision surgery. As PMMA cement was strongly adhered to the bone, it was removed together with cancellous bone. Histologically, HA granules bound to the bone directly after bone ingrowth into the spaces around the HA granules. This is the reason we have described IBBC as a method having the both advantages of cementless HA coating and PMMA bone cement. After the revision surgery, the walking ability was improved. In conclusion, this case showed excellent characteristics of IBBC

Revision of the femoral component during revision hip arthroplasty may pose significant technical challenges, most notably femoral fracture and bone perforation. The in-cementing technique allows use of the original bone-cement interface which has been proven to be biomechanically stronger than recementing after complete removal of the original cement mantle.

This study reviews a series of 54 consecutive revision hip arthroplasty procedures carried out by the senior author using the in-cementing technique from November 1999 to March 2003. Patients were followed up clinically and radiologically with serial outpatient reviews and their functional outcome was assessed using the Harris hip scoring system, the Oxford hip scoring system and the University of California at Los Angeles (UCLA) activity profile. Their physical and mental well-being was also assessed using the SF-36 self-questionnaire.

Fifty-four procedures were performed on 51 patients. There were 31 males and 20 females. The average age was 70.3+/-8.1 years (range: 45-83 years). The average time to revision from the original procedure was 132.8+/-59.0 months (range: 26-286 months). The average length of follow-up was 29.2+/-13.4 months (range: 6-51 months) post revision arthroplasty. Two patients suffered dislocations, one of which was recurrent and was revised with a Girdlestone's procedure. No patient displayed any evidence of radiographical loosening. The average Harris hip score of the study group was 85.2+/-11.6 (range: 51.9-98.5). The average Oxford hip score recorded was 19.6+/-7.7 (range: 12-41) and the average UCLA activity profile score was 5.9+/-1.6 (range: 3-8). The SF-36 questionnaire had an average value of 78.0+/-18.3 (range: 31.6-100).

In conclusion, the results of this study show excellent clinical and radiological results of the in-cementing technique with high patient satisfaction in terms of functional outcome. This technique merits consideration where possible in revision hip arthroplasty.

Aims. The main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray. Methods. In order to determine the best tibial tray cementation technique, we applied cement to 40 cryopreserved donor tibiae by four different techniques: 1) double-layer cementation of the tibial component and tibial bone with bone restrictor; 2) metallic cementation of the tibial component without bone restrictor; 3) bone cementation of the tibia with bone restrictor; and 4) superficial bone cementation of the tibia and metallic keel cementation of the tibial component without bone restrictor. We performed CT exams of all 40 subjects, and measured cement layer thickness at both levels of the resected surface of the epiphysis and the endomedular metaphyseal level. Results. At the epiphyseal level, Technique 2 gave the greatest depth compared to the other investigated techniques. At the endomedular metaphyseal level, Technique 1 showed greater cement penetration than the other techniques. Conclusion. The best metaphyseal cementation technique of the tibial component is bone cementation with cement restrictor. Additionally, if full tibial component cementation is to be done, the cement volume used should be about 40 g of cement, and not the usual 20 g. Cite this article: Bone Joint Res 2021;10(8):467–473

Abstract. Introduction. Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA) and this has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA. Methodology. A UK based, three round, online modified Delphi Expert Consensus Study was completed focussing on cementation technique in TKA. Experts were identified as having a minimum of 5 years Consultant experience in the NHS and fulfilling any one of the following three criteria:. · A ‘high volume’ knee arthroplasty practice (>150 TKA per annum) as identified from the National joint registry (NJR). · A senior author of at least 5 peer reviewed articles related to TKA in the previous 5 years. · A named trainer for a post CCT fellowship in TKA. Results. Eighty-one experts (Round 1) and eighty experts (Round 2 and 3) completed the Delphi Study. Four domains with a total of twenty-four statements were identified. 100% consensus was reached within the cement preparation, pressurisation, and cement curing domains. 90% consensus was reached within the cement application domain. Consensus was not reached with only one statement regarding the handling of cement during initial application to the tibial and/or femoral bone surfaces. Conclusion. The CeTIKS expert consensus study presents comprehensive recommendations on the optimal technique for component cementation in TKA. Expert opinion has a place in the hierarchy of evidence and until better evidence is available these recommendations should be considered when cementing a TKA

The use of endoprosthesis implants is frequent for tumours involving the proximal third of the femur and not amenable to primary arthroplasty or internal fixation. In this population, these implants are preferentially cemented given poor bone quality associated with systemic diseases and treatments. Loosening is a common complication of these implants that have been linked to poor bone quality, type of implants and importantly cementing technique. Thus, these techniques vary between different surgeons and based mainly on previous experience. One of the most successful cementing techniques in the arthroplasty literature is the French paradox. This technique involves removing the cancellous bone of the proximal femoral metaphysis and selects the largest stem to tightly fit the created cavity delineated by cortical bone. Cementing the implant results in a very thin cement layer that fills the inconsistent gaps between the metal and the bone. To our knowledge, no previous report exists in the literature assessing loosening in proximal femur replacement using the French paradox cementing technique. In this study, we sought to examine (1) rates of loosening in proximal femur replacement, and (2) the oncological outcomes including tumour recurrence and implant related complications. A retrospective study of 42 patients underwent proximal femur replacement between 1990 and 2018 at our institution. Of these, 30 patients met our inclusion criteria. Two independent reviewers have evaluated the preoperative and the most recent postoperative radiographs using the International Society of Limb Salvage (ISOLS) radiographic scoring system and Gruen classification for femoral stem loosening. Additionally, the acetabulum was evaluated for erosion according to the criteria of Baker et al. The mean age of this cohort was 60.5 (19–80), with 60% being males. The primary origin was metastatic in 17 (56.7%) patients, bone sarcoma in 10 (33.3%) patients and soft tissue sarcoma in 3 (10%) patients. Pathological fractures were present in 11 (36.7%) patients. Seven (23.3%) patients had prior intramedullary nailing. Preoperative radiotherapy was used in 8 (26.7%) and postoperative radiotherapy in 17 (56.7%) patients. The mean clinical follow-up was 25.2±26.3 months and the mean radiographical follow-up was 24.8±26 months. The mean ISOLS score for both reviewers was found to be 89±6.5% and 86.5±6.1%, respectively. Additionally, the first reviewer found two patients to be possibly loos (6.7%) compared to one (3.3%) patient for the second reviewer. No components scored as probably or definitely loose and non-required revision for either loosening or metal failure. Furthermore, both reviewers showed no acetabular erosion in 25 (83.3%) and 24 (80%) patients, respectively. On the other hand, the overall rate of complications was 36.6% with 11 complications reported in 30 patients. Local recurrence occurred in five (16.6%) patients. Prosthetic Dislocation was the most frequent complications with eight dislocations in four patients. Despite complications, our results showed no radiographic evidence of stem loosening. Cementing proximal femur prosthesis with a tight canal fit and with a thin cement mantle appears to be a viable option at short and medium term

Background. The acknowledged benefit of the direct anterior (DA) approach is early functional return. Most surgeons in the U.S. use cementless femoral replacement given the negative track record of some cemented designs. However, delayed osseointegration of a femoral stem typically seen in older patients with poor bone quality will delay recovery, diminishing the benefits of the DA approach. Registry studies have shown a higher revision rate and complications in this patient population leading to a renewed interest in cemented fixation. Questions posed. To achieve the functional benefits of the DA approach and the fixation benefits of cemented replacement, this study combined the 2 techniques posing the following questions:1) Does the limited access of the DA approach adversely affect the cement technique? 2) Does such a cementing technique reduce the incidence of cementless complications?. Methods. A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016–2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 in the cementless group and 76 in the cemented group, 70% females. Femoral complications were compared between the 2 groups using the T-test. Results. The cementless group had a higher rate of femoral complications (8 versus 0, P=0.011). There were 2 loose stems and 6 fractures, all requiring revision. Fractures occurred about 14.5 days and loosening about 10 months postoperatively. Conclusion. A higher rate of complications occurred with cementless stems. Cemented stems are protective in patients above 70 and can be safely done through the DA approach

Aims. Anchorage of pedicle screw rod instrumentation in the elderly spine with poor bone quality remains challenging. Our study aims to evaluate how the screw bone anchorage is affected by screw design, bone quality, loading conditions, and cementing techniques. Methods. Micro-finite element (µFE) models were created from micro-CT (μCT) scans of vertebrae implanted with two types of pedicle screws (L: Ennovate and R: S. 4. ). Simulations were conducted for a 10 mm radius region of interest (ROI) around each screw and for a full vertebra (FV) where different cementing scenarios were simulated around the screw tips. Stiffness was calculated in pull-out and anterior bending loads. Results. Experimental pull-out strengths were excellently correlated to the µFE pull-out stiffness of the ROI (R. 2. > 0.87) and FV (R. 2. > 0.84) models. No significant difference due to screw design was observed. Cement augmentation increased pull-out stiffness by up to 94% and 48% for L and R screws, respectively, but only increased bending stiffness by up to 6.9% and 1.5%, respectively. Cementing involving only one screw tip resulted in lower stiffness increases in all tested screw designs and loading cases. The stiffening effect of cement augmentation on pull-out and bending stiffness was strongly and negatively correlated to local bone density around the screw (correlation coefficient (R) = -0.95). Conclusion. This combined experimental, µCT and µFE study showed that regional analyses may be sufficient to predict fixation strength in pull-out and that full analyses could show that cement augmentation around pedicle screws increased fixation stiffness in both pull-out and bending, especially for low-density bone. Cite this article: Bone Joint Res 2021;10(12):797–806