In the 1960's Sir John Charnley introduced to clinical practice his low friction arthroplasty with a highly polished cemented femoral stem. The satisfactory long term results of this and other cemented stems support the use of polymethylmethacrylate (PMMA) for fixation. The constituents of PMMA remain virtually unchanged since the 1960s. However, in the last three decades, advances in the understanding of cement fixation, mixing techniques, application, pressurization, stem materials and design provided further improvements to the clinical results. The beneficial changes in cementing technique include femoral preparation to diminish interface bleeding, pulsatile lavage, reduced cement porosity by vacuum mixing, the use of a cement restrictor, pre-heating of the stem and polymer, retrograde canal filling and pressurization with a cement gun, stem centralization and stem geometries that increase the intramedullary pressure and penetration of PMMA into the cancellous structure of bone. Some other changes in cementing technique proved to be detrimental and were abandoned, such as the use of Boneloc cement that polymerised at a low temperature, and roughening and pre-coating of the stem surface. In the last two decades there has been a tendency towards an increased use of cementless femoral fixation for primary hip arthroplasty. The shift in the type of fixation followed the consistent, durable fixation obtained with uncemented acetabular cups, ease of implantation and the poor results of cemented femoral fixation of rough and pre-coated stems. Unlike cementless femoral fixation, modern cemented femoral fixation has numerous advantages: it is versatile, durable and can be used regardless of the diagnosis, proximal femoral geometry, natural neck version, and bone quality. It can be used in combination with antibiotics in patients with a history or predisposition for infection. Intra-operative femoral fractures are rare. However, the risk may be increased in collarless polished tapered stems. Post-operative thigh pain is extremely rare. Survivorship has not been surpassed by uncemented femoral fixation and it continues to be my preferred form of fixation. However, heavy, young, male patients may exhibit a slightly higher aseptic loosening rate

In the 1960s Sir John Charnley introduced to clinical practice his low friction arthroplasty with a highly polished cemented femoral stem. The satisfactory long term results of this and other cemented stems support the use of cement for fixation. The constituents of acrylic cement remained virtually unchanged since the 1960s. However, in the last three decades, advances in the understanding of cement fixation, mixing techniques, application, pressurization, stem materials and design provided further improvements in the clinical results. The technical changes in cementing technique that proved to be beneficial include femoral preparation to diminish interface bleeding, careful lavage, reduced cement porosity by vacuum mixing, a cement restrictor, pre-heating of the stem and polymer, retrograde canal filling and pressurization with a cement gun, stem centralization and stem geometries that increase the intramedullary pressure and intrusion into the bone of the cement. Some other changes proved to be detrimental and were abandoned, such as the use of Boneloc cement that polymerised at a low temperature, and roughening and pre-coating of stem surface. In recent years there has been a tendency towards an increased use of cementless femoral fixation for primary hip arthroplasty. The shift in the type of fixation followed the consistent, durable fixation obtained with uncemented acetabular cups, ease of implantation and the poor results of cemented femoral fixation of rough and precoated stems. Unlike cementless femoral fixation, modern cemented femoral fixation has numerous advantages: it's versatile, durable and can be used regardless of the diagnosis, proximal femoral geometry, natural neck version, and bone quality. It can be used in combination with antibiotics in patients with a history or predisposition for infection. Intraoperative femoral fractures and postoperative thigh pain are extremely rare. Survivorship has not been surpassed by uncemented femoral fixation and it continues to be my preferred form of fixation. However, heavy, young male patients may exhibit a slightly higher aseptic loosening rate

Abstract. Methodology. Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. 76 cases (mean age of 33.2 years) who had primary ACL reconstruction with BTB or quadriceps tendon with bone block, were divided into 2 matched groups (age, sex and type of graft) of 38 each based on the method of femoral fixation used (interference screw or adjustable cortical suspension). Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Complications and return to theatre were noted. Paired two-tailed student t-tests and Chi-square tests were employed for statistical analysis. Results. At a mean follow-up of 82 months, peri-operative mean EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.05), but no significant difference between the two groups (p>0.05). Mean graft length and diameter was 77mm and 9.3 respectively. Mean interval from injury to surgery was 10.5 months. 18(23.7%) patients had associated meniscal tear with 73.3 % undergoing repair. 10 cases (13.2 %) returned to theatre including, MUA for arthrofibrosis (n=2) and intra-substance graft failure (n=2). 3 cases had to be converted to interference screw fixation due to the tightrope cutting through from the femoral bone block as a result of a technical pitfall. Conclusion. Primary ACL reconstruction using adjustable cortical suspension on femoral side for BTB or quadriceps bone-block tendon graft is a safe technique with added advantages of 360 degree bone ingrowth and no screw in the femoral tunnel

Purpose: This prospective comparative study examined the two-year results of two femoral fixation method for anterior cruciate ligament (ACL) repair using the four-part hamstring technique. A consecutive series of 60 patients with the same tear criteria involving the ACL alone were randomly assigned to the two treatment arms. Femoral fixation was achieved by mixed corticocancellous transfixation or by interference screw fixation. Material and methods: The series included two cohorts of 30 patients each. We excluded patients with a history of ligament or bone surgery and those with associated lesions of the peripheral ligaments. Complementary lateral reinforcement was not performed in either group. The interference screw fixation group had 20 men and 10 women, mean age 29 years (14–48), 18 right side. The blind femoral tunnel was drilled arthroscopically. The transfixation group included 19 men and 11 women, mean age 26 years (16–40), 17 right side. The blind femoral tunnel was drilled via a transtibial approach using the Rosenberg aiming procedure. In both cohorts, tibial fixation of the transplant was achieved with a resorbable polylactic screw measuring at least the diameter of the tibial tunnel. Statistical analysis of results (Statview 4.5) was based on the clinical IKDC score, thigh volume, and level of sports activity. Telos at 15 and 20 kg was used to measure laxity. Results: Mean delay to review was 24 months (22–26). The two cohorts were comparable preoperatively (laxity, sports level, meniscal or cartilage lesions). There was no statistical difference for joint amplitudes, joint instability, or level of sports activity at last follow-up. The telos differential laxity at 15 kg was statistically lower in the interference screw fixation group (mean 1.1 mm) than in the transfixation group (mean 1.4 mm) (p < 0.01). There were no complications in either group, particularly no cyclope syndrome. Radiographically, there was no statistical difference for the position of the tibial tunnel. The femoral tunnel was however different: the Aglietti index was 0.57 for transfixation and 0.62 for interference screw fixation (p < 0.01). Discussion: This prospective study demonstrated the good mid-term anatomic results after 4-part hamstring plasty of the ACL for both types of femoral fixation (transfixation or interference screw fixation). The position of the femoral tunnel appeared to be better with interference screw fixation, with a statistical correlation with better anatomic results (telos). This suggests that the transtibial femoral aiming procedure does not necessarily produce a totally satisfactory isometric alignment

Introduction. In the United States, cementless femoral fixation remains the dominant mode of fixation for femoral neck fractures, despite strong worldwide registry data that supports cemented fixation. The reason for this discrepancy remains unknown, controversial and often difficult to compare due to multiple variables. The purpose of this study was to evaluate a matched cohort of patients undergoing arthroplasty for femoral neck fractures and assess outcomes of revisions, periprosthetic fractures and mortality. Methods. This is an exact matched cohort study. Cemented fixation cases were exact matched to cementless fixation cases in a 1:1 fashion based on age, sex and Charlson Comorbidity Index (CCI). Outcome variables included: revision for periprosthetic fracture; all cause revision and mortality at any time point; all cause revision and mortality within 1-year and within 90-days. The primary independent variable was femoral fixation (cemented, cementless) and covariates included race (black, white, other), ethnicity (hispanic, non-hispanic), teaching status (minor, major, nonteaching) and bedsize (1–99, 100–399, >=400). Chi-square tests and multivariable logistic regression models were used for statistical analysis. Results. A total of 64,283 femoral neck fractures were evaluated. 17,138 cementless femoral stems were matched exactly to cemented femoral stems based on age, gender and Charleston comorbidity index (CCI). In the multivariate logistic regression analysis, compared to cementless femoral fixation, cemented fixation was associated with a 20% reduction in overall revision (OR 0.796, 0.675–0.939), a 30% reduction in revision at 1 year (OR: 0.709, 0.589–0.854) and a 86% reduction in revision for periprosthetic fracture (OR: 0.144, 0.07–0.294). However, cemented stem fixation was associated with a 23% (OR: 1.33, 1.134–1.338) and 16% (OR: 1.232, 1.134–1.338) increase in mortality at 90 days and 1 year post op respectively. Conclusions. In this exact matched cohort study, risk of early revision and revision for PPFx was dramatically reduced at all time points with the use of cemented stem fixation for elective THA and FNF. However, the increased risk of 90d and 1 year mortality following cemented stem fixation in the elective population warrants further investigation

Graft fixation in anterior cruciate ligament reconstruction is a basic criterion for the outcome of the surgical procedure. Several solutions have been proposed; each of them had advantages and disadvantages, and the choice of a surgical technique often represents the surgeon’s opinion. The goal of the fixation is stability and incorporation of the graft in the bone tunnels. Bone-patellar tendon-bone graft has the advantage of bone to bone fixation, which is impossible using tendon grafts. Femoral fixation techniques for hamstrings can be classified as follows: compression techniques, expansion techniques and suspension techniques (cortical or cancellous). Top Traction System (TTS) is a new technique for femoral fixation using hamstrings. Here, a retrograde screw is fixed to the anterolateral cortex of the femur. A ring is fixed to the screw to pass the tendons.The screw is self-threading, 28 mm long and 6.5 mm in diagmeter; its pull-out strength is 1350 N. The screw is made from a titanium alloy and only available in one size. Surgical technique is simple and reproducible and the instruments are easy to use. The positioning of the screw is fully guided by instruments that minimise errors. With this fixation device further graft traction is possible after tibial fixation without twisting the hamstrings. Results are good at the short-term evalutation but a long-term follow-up is required before a final recommendation can be made

There exist 4 methods for femoral fixation of hip spacers:. a simple insertion,. a partial/full cementation,. the “glove”-technique, and,. a cement bridge in case of large osseous defects of the proximal femur. To our knowledge, it is still unknown which of these methods provides the best stability. Between 01.01.1999–31.12.2008, 84 hip spacer implantations in 78 patients have been performed in our department. All patients have been treated with the same kind of spacer. 24 spacers have been fixed with the “glove”-technique, 18 with a partial cementation onto the proximal femur, 21 with a simple insertion, and 4 with a cement bridge. In 17 cases with an isolated septic loosening of the acetabular cup, only a spacer head has been placed onto the well-fixed prosthesis stem. The overall dislocation rate between stages was 21.4 % (18/84). The lowest dislocation rate was observed in the “spacer head” group with 5.8 % (1/17), followed by the “glove”-technique with 12.5 % of the cases (3/24). In the “partial cementation” group the dislocation rate was 22.2 % (4/18), whereas in the “insertion” group spacer dislocations occurred in 9 out of 21 cases (42.8 %). In the latter group, in 3 cases the spacer rotated primarily in the femur and dislocated subsequently out from the acetabulum. From the 4 patients having been treated with a cement bridge, 2 patients suffered from a spacer dislocation. From these 18 cases, 15 patients have been treated conservatively by reduction and immobilization in a hip orthesis during the remaining time between stages. The other three cases underwent further surgical procedures; in one case (combined spacer dislocation and -fracture), the spacer had been exchanged, whereas the other two cases had been treated by resection arthroplasty after recurrent spacer dislocations and unsuccessful conservative treatment. The “glove”-technique seems to be the most effective method for femoral fixation fixation of hip spacers regarding the prevention of dislocations between stages. Further advantages of this technique include a safe and easy spacer explantation in one piece without cement debris at the second stage

Introduction: After adopting a new low suspensory bio-absorbable femoral fixation technique for single bundle, four strand, hamstring Anterior Crutiate Ligament (ACL) in conjunction with a rapid rehabilitation program, we observed at routine follow up that there was no evidence of femoral tunnel widening, as often observed with conventional high suspensory fixation systems. Method: We conducted a retrospective observational cohort study to test the hypothesis that the Rigid-Fix (Mitek) system of femoral fixation, a low suspensory technique, is less prone to tunnel widening than traditional suspensory techniques. 14 subjects were recruited at routine follow up, and assessed by interview, clinical examination and plain digital raiodgraphs. All radiographs were taken under clinical supervision, with a scale reference, hence allowing digital rescaling. Results: All subjects had regained knee stability, and all but one had returned to their pre-injury level of sport. Clinically all knees were ligamentaly stable, exhibiting negative Luchman and pivot shift tests. Examination of the radiographs demonstrated only a 1.1mm (+/− 0.9mm) mean femoral tunnel widening, which represents a 12% increase in diameter (21% increase in area), and compares very favourably to the observed tunnel widening in high suspensory techniques, as cited in the literature. Conclusions: We conclude that the Rigid-Fix femoral ACL fixation system does not exhibit any evidence of clinically significant tunnel widening, even when used in conjunction with a rapid rehabilitation program. Systems of low suspension benefit from the advantage of not relying on interference fit which risks posterior cortical ‘Blow Out’. A shorter graft working length within the tunnel lessens graft micro-movement, making early low biological fixation within the femoral tunnel more likely, and reduces the amount of tunnel widening. These micro-movement have been described as the ‘Windscreen Wiper’ and ‘Bungee Cord’ effects, and are well documented in traditional high suspensory fixation

Transverse pin femoral fixation of bone-patella tendon-bone (BPTB) in ACL reconstruction has been widely applied during the last decades. Aim of our study is to confront two different system of transverse femoral fixation for BPTB graft: Transfix BTB (Arthrex) and BioTransfix T3 (Arthrex). The main differences between these two system are the diameter (3.0 mm Transfix BTB and 3.5 mm BioTransfix T3), and section (Transfix BTB is cannulated). Surgical technique adopts the same transverse vectorial guide but different guide sleeves. 30 fresh-frozen porcine knees (mean age 2.2 years) were assigned to the two groups randomisedly. the patellar bone block and tendon were harvested using the same size in all specimens (10mm × 25 mm, 10 mm). Zwick-Roell z010 tension/compression device with bone clamps, was used for the study:. Cyclic test (1000 cycles, 0.5 Hz, 50–250 N/cycle, 100 cycles of preload). Final pull-out test (1 mm/s). Failure analysis. CT scan and densitometry. Any implant didn't fail during cyclic test. The elongation average was 1.85±0.63 for Transfix BTB and 1.69±0.87 for BioTransfix T3. Pull-out test showed very similar values in terms of Ultimate Strength Failure (USF), Stiffness at USF, and Stiffness:. The failure mode was bone plug fracture (12 for Transfix BTB and 13 for BioTransfix T3) and tendon failure (3 for Transfix BTB and 2 for BioTransfix T3). The post-test CT scan showed any failure of the fixation devices and the correct position inside the femoral half-tunnel. The mean bone density of porcine femora was comparable to young human femora (1.12±0.31 BMD). Both systems showed a similar behaviour in terms of USF, Stiffness, Cyclic load, method of failure and other biomechanical parameters. The reproducibility of surgical technique, the mechanical strength and endurance of the systems suggest two valid options for ACL reconstruction with BPTB even if in-vivo studies are necessary to confirm the animal ex-vivo biomechanical data

Introduction: The aim of this study was to compare two methods of femoral fixation for four strand Hamstring (4SH) primary ACL reconstruction: namely a recently introduced suspensory fixation using absorbable polylactic acid cross pins versus our traditional method of anchor fixation. Method: Forty-five consecutive patients, who had undergone primary ACL reconstruction using 4SH graft and the suspensory femoral fixation were prospectively evaluated by an independent observer. IKDC scores were recorded and laxity was assessed using cruciometer. These results were compared with a similar well-matched cohort of patients whose femoral fixation was with an anchor. Tibial fixation in both the groups was similar. Results: No significant difference was noted between the two groups on comparison of IKDC scores or cruciometer readings at a minimum one-year follow-up. Conclusions: This suspensory method of femoral fixation for a four-strand hamstring graft provided a secure fixation with satisfactory early clinical results. As this method of fixation is a new technique, further follow-up is needed for long-term validation

The chioce of the graft and its fixation in LCA reconstruction is basic for the outcome of the surgical procedure. Several solutions have been proposed; each of them had advantages and disavantages. The choice of the graft and the surgical technique is often due to surgeon’s opinion. The goal of the fixation is stability which allowes incorporation of the graft in the bone tunnels. Bone-patellar tendon-bone graf has the advantage of bone to bone fixation which is impossible using tendon grafts. Femoral fixation techniques for hamstrings can be classified in: compression tecniques, expansion tecniques and suspension tecniques (cortical or canellous). TTS (Top Traction System) is a new tecnique for femoral fixation using hamstrings. The fixation is achieved by a retrograde screw that allowes fixation to the antero-lateral cortex of the femur. A ring is fixed to the screw to allow tendons passing. The screw is sefl-threading, its lenght is 28 millimeters and its diameter is 6,5 millimeter; its pull-out strenght is 1350 N. The screw is built in titanium alloy and only one size. Surgical technique is simple an reproducible and the instruments are easy to use. The positioning of the screw is fully guided by instruments that minimize errors. This fixation device allowes further graft traction after tibial fixation without twisting hamstrings. Results after 5 years are good but we need long term follow-up for final opinion

The initial success of modern total hip arthroplasty can in large part be attributed to the reliable fixation of the femoral component with the use of acrylic bone cement. Early success with cement led to a common pathway of development in North America and the European countries. Much of the early- to mid-term research concentrated on refinement of variables related to the methodology and technique of cement fixation. Scandinavian registries were subsequently able to report on improved survivorship with better cementing technique. The net effect has been standardisation towards a small number of cemented implants with good long-term outcomes representing the majority of stems implanted in Sweden, for example. In North America, during the mid-term development of THA in the late 1980's, the term “cement disease” was coined and the cemented THA saw a precipitous decline in use, now to the point where many American orthopaedic residents are completing training never having seen a cemented THA. Modern uncemented femoral components can now claim good long-term survivorship, perhaps now comparable to cemented fixation. However, this has come at a cost with respect to the premium expense applied to the implant itself as well as lineage of failed uncemented constructs. The last several years have seen a proliferation of uncemented implants, usually at a premium cost, with no demonstrated improvement in survivorship. Osteolysis has not been solved with uncemented implants and cement disease has largely been recognised as a misnomer. Long-term outcomes of cemented femoral fixation have consistently demonstrated excellent survivorship, even in the younger age group. Cemented stems allow for variable positioning of the stem to allow for better soft tissue balancing, without the need for proximal modularity. Cemented stems are more forgiving and fail less often secondary to a reduced incidence of intraoperative complications, such as periprosthetic fracture. Cemented stems tend to be less expensive and also have the advantage of adding antimicrobial agents into the cement. This is important in emerging markets. The next iteration of orthopaedic innovation driven by the emerging markets may indeed be back to the future

Thirty- seven patients were enrolled in a single-blind prospective randomized clinical trial comparing the use of the Endopearl in femoral fixation in otherwise similar anterior cruciate ligament (ACL) reconstructions. Evaluation pre-operatively, three months, six months and eighteen months post-operatively suggested significant difference in the side to side KT-1000 values suggesting improved graft fixation with the EndoPearl by eighteen months post surgery with no differences in the Mohtadi ACL QOL questionnaire. Thus, when bioabsorbable interference screws are used for ACL reconstruction, the use of the EndoPearl improves anterior-posterior stability up to eighteen months post-operatively. The EndoPearl is an adjunct to bioabsorbable interference screw fixation in the femoral tunnel in ACL reconstruction. The purpose of the study was to assess the clinical effectiveness of the EndoPearl using the KT-1000 Knee Arthrometer and the Mohtadi ACL Quality of Life (ACL-QOL) Questionnaire. The application of the EndoPearl in hamstring ACL reconstruction has no significant benefit when compared to conventional treatment in KT-1000 and ACL-QOL Questionnaire outcomes. Prospective Single-blind Randomized Clinical Trial. ACL reconstruction with autogenous semitendino-sus and gracilis tendons was performed on thirty-seven patients. Pre-operatively, three months, six months and a eighteen months post-operatively, patients’ knees were evaluated using the KT-1000 Knee Arthrometer and the ACL-QOL questionnaire. Statistically significant differences were achieved in terms of KT-1000 side-to-side differences between the study group and the control group at six months and eighteen months post-operatively; the mean-side-to-side differences are significantly less in the study group when compared to the control group. Statistically significant differences could not be detected when comparing the ACL-QOL questionnaire between the two groups. The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased laxity up to eighteen months post-operatively in terms of KT-1000 side-to-side differences. In an accelerated post-operative rehabilitation program, patients and doctors have increased confidence in terms of graft stability with the application of the Endo-Pearl in hamstring ACL reconstruction. Please contact author for pictures and/or diagrams

Tibial and femoral bone tunnel widening (TW) has been observed following anterior cruciate ligament (ACL) reconstruction. We developed a χ12 mm cannulated cancellous screw (Intercondylar Ligament Screw, ICLS) for femoral fixation to reduce TW. The purpose of this study is to introduce our surgical method and its results. We employed an original ICLS system developed to reduce the needed distance between the tibial and femoral-fixation points (distance between fixation points, DbF) in ACL reconstruction. Five-strand (sometimes four or six-strand) hamstring grafts are connected to the ICLS. Tibial fixation is achieved with a Ligament Tension Screw, which had been developed by Murase et al. rom 2001 to 2008, 169 knees underwent ACL reconstruction at our hospitals using our ICLS system. TW was evaluated by radiographs at least three months postoperatively. An enlargement of more than 2 mm was considered TW. The following was also evaluated: range of motion, the limb symmetry index (LSI, injured leg divided by uninjured and multiplied by 100), value of knee extension power in OKC, anterior knee laxity, Lysholm score, and DbF. The average length of DbF was 38.1 mm (n=132). Only 6.7% (n=104) of cases showed more than 2 mm of TW. Mean LSI was 83.3%(n=77) four months postoperatively. The mean Lysholm score was 96.2(n=68) at three months after ACL reconstruction. The mean side-to-side difference in anterior tibial translation, measured with use of a KT-2000 or Knee Lax, was 1.60 mmï1/4N=57ï1/4‰. We were able to reduce TW after ACL reconstruction using our ICLS system with good results

Aim: To determine if a side-to-side difference in laxity occurs with anterior cruciate ligament (ACL) reconstruction utilizing a hamstring tendon and standard RCI (Smith and Nephew) interference screw fixation, and if this can be affected by the use of a reverse thread RCI screw in right-sided knees. Methods: This was a prospective study of 80 patients undergoing right-sided ACL reconstruction with hamstring tendon autograft. Females were excluded in case of there being a sex difference in postoperative laxity with HT graft. The study group comprised of 36 males utilising standard RCI screws (STD) and 44 males utilising reverse-thread RCI screws (REV). The same technique was used on all patients and all procedures were carried out by the same surgeon. The patients were evaluated at six and 12 months following the surgery with KT1000, IKDC assessment, and Lysholm Knee Score. Results: At the follow-up after 12 months, the average side-to-side differences using KT1000 testing were 2.0 mm (STD) and 1.0 mm (REV) using manual maximum, and 1.7 (STD) and 1.0 (REV) using KT20. Both results were statistically significant. In addition, 33% of the STD group had a manual maximum of ≥3mm compared with 11% of the REV group (p< 0.01). Accordingly, there was a higher incidence of grade I instability (Lachman) in the STD group (23% of STD group; 8% of REV group, p=0.04). Conclusion: The use of a reverse-thread interference (RCI) screw for femoral fixation in right-sided hamstring tendon ACL reconstructions in males significantly decreased side-to-side laxity at the 12 month review when compared with standard RCI fixation

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union.

We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity.

For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I²= 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain.

We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation.

The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different. In the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group.

Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success.

The author's personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups.

The author's current indication for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection.

Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component.

The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is an extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000.

A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems, unfortunately, may continue to go down as it is uncommonly taught in residency and fellowship, however, it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons armamentarium when treating patients undergoing primary and revision THA.

The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different, in the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group.

Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success. The authors' personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups.

The authors' current indications for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection. Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component.

The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is a extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000.

A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems unfortunately may continue to go down as it is uncommonly taught in residency and fellowship, however it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons' armamentarium when treating patients undergoing primary and revision THA.

A large body of the orthopaedic literature clearly indicates that the cement mantle surrounding the femoral component of a cemented total hip arthroplasty should be at least 2 mm thick. In the early 1970s, another concept was introduced and is still in use in France consisting of implanting a canal filling femoral component line-to-line associated with a thin cement mantle. This principle has been named the “French paradox”. An explanation to this phenomenon has been provided by in-vitro studies demonstrating that a thin cement mantle in conjunction with a canal filling stem was supported mainly by cortical bone and was subjected to low stresses. We carried out a study to evaluate the in-vivo migration patterns of 164 primary consecutive Charnley-Kerboull total hip replacements. All prosthesis in the current series combined an all-polyethylene socket and a 22.2 mm stainless steel femoral head. The monobloc double tapered (5.9 degrees) femoral component was made of 316L stainless steel with a highly polished surface (Ra = 0.04 μm), a quadrangular section, and a neck-stem angle of 130 degrees. The stem was available in six sizes with a stem length (shoulder to tip) ranging from 110 mm to 160 mm, and a neck length ranging from 24 mm to 56 mm. For each size, the femoral component was available in two to four different diameters to adapt the implant to the medullary canal. Hence the whole range comprised a total of 18 standard femoral components. The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational and varus/valgus stability of the stem prior to the line-to-line cementation. We used the Ein Bild Roentgen Analyse Femoral Component (EBRA-FCA) method to assess the subsidence of the femoral component. At the minimum 15-year follow-up, 73 patients were still alive and had not been revised at a mean of 17.3 years, 8 patients had been revised, 66 patients were deceased, and 8 patients were lost to follow-up. The mean subsidence of the entire series was 0.63 ± 0.49 mm (0 – 1.94 mm). When using a 1.5 mm threshold, only four stems were considered to have subsided. With revision of either component for any reason as the endpoint, the cumulative survival rate at 17 years was 90.5 ± 3.2% (95% CI, 84.2% to 96.8%). With radiological loosening of the femoral component as the endpoint, the cumulative survival rate at 17 years was 96.8 ± 3.1% (95% CI, 93.2% to 100%). This study demonstrated that, in most cases, a highly polished double tapered stem cemented line-to-line does not subside up to 18-year follow-up.

Introduction: Over the last 37 years I have performed more than 8000 primary and revision THRs. These include cemented, hybrid, and noncemented types of fixation. There are many preventable complications which include: infection, delayed wound healing, perforation or varus position of the implant, and suboptimal cement technique. Quality of function depends on restoring center of rotation, restoring offset, equal limb length, balancing soft tissue, and adequate pain control. Long-term success depends on durable fixation and reduced wear. Cement fixation into cortico-cancellous bone provides durable fixation.

Discussion: We have a cohort at my practice of 370 total hip replacements. Fifty-three percent were cemented, 25% were hybrid, and 22% were noncemented. In another cohort of 253 cemented THR followed for a 10-year period, only two failures were found. One revision was for dislocation and the other was for loosening. I have found the Interlock system to have a very successful survivorship rate. I believe the reason for superior results is better polyethylene, better patient selection, and better surgical technique. I indicate cemented fixation for patients 60 years and older. I avoid if there is excessive bleeding and in a heavy, active patient.