Standard practice in revision total hip replacement (THR) for periprosthetic fracture (PPF) is to remove all cement from the femoral canal prior to implantation of a new component. This can make the procedure time consuming and complex. Since 1991 it has been our practice to preserve the old femoral cement where it remains well fixed to bone, even if the cement mantle is fractured, and to cement a new component into the old mantle. We have reviewed the data of 48 consecutive patients, treated at our unit between 1991 and 2009, with a first PPF around a cemented primary THR stem where a cement in cement revision was performed. 8 hips were revised to a standard length stem, 39 hips to a long stem & 1 patient had the same stem reinserted. All fractures were reduced and held with cerclage wires or cables and four had supplementary plate fixation. Full clinical and radiographic follow up was available in 38 patients & clinical or radiographic follow up in a further 6 patients. The other 4 patients. without follow up but whose outcome is known, have suffered no complications and are pain free. Of the remaining 44 patients, forty-two went on to union of the fracture and two have required further surgery for non-union. One patient has ongoing undiagnosed hip pain. Our long term experience with cement in cement revision for periprosthetic femoral fractures shows that this is a viable technique with a low complication rate and high rate of union (95%) in what is generally regarded as a very difficult condition to treat

Osteosarcoma and other types of bone cancers often require bone resection, and backfill with cement. A novel silorane-based cement without PMMA's drawbacks, previously developed for dental applications, has been reformulated for orthopedic use. The aim of this study is to assess each cement's ability to elute doxorubicin, maintain its potency, and maintain suitable weight-bearing strength. The silorane-based epoxy cement was synthesized using a platinum-based Lamoreaux's catalyst. Four groups of cement were prepared. Two PMMA groups, one without any additives, one with 200 mg of doxorubicin. Two silorane groups: one without any additive, one with doxorubicin, added so that the w% of drug into both cements were equal. Pellets 6 × 12 mm were used for testing (ASTM F451). n=10. Ten pellets from each group were kept dry. All others were placed into tubes containing 2.5 mL of PBS and stored at 37 °C. Elution from doxorubicin-containing groups were collected every day for 7 days, with daily PBS changeout. Antibiotic concentrations were determined via HPLC. Compressive strength and compressive modulus of all groups were determined for unsoaked specimens, and those soaked for 7 and 14 days. MTT assays were done using an MG63 osteosarcoma cell line. Both cements were able to elute doxorubicin over 7 days in clinically-favorable quantities. For PMMA samples, the incorporation of doxorubicin was shown to significantly affect the compressive strength and modulus of the samples (p<0.01). Incorporation of doxorubicin into silorane had no significant effect on either (p>.05). MTT assays indicated that doxorubicin incorporated into the silorane cement maintained its effectiveness whereas that into PMMA did not. At the dosing used, both cements remained above the 70 MPa. Both PMMA and silorane-based cements can deliver doxorubicin. Doxorubicin, however, interacts chemically with PMMA, inhibiting polymerization and lowering the chemotherapeutic's effectiveness

Introduction: The failure rate of cemented hip replacements is about 1% per year, mainly due to aseptic loosening. PMMA acts as a grout, therefore high pressure is needed to ensure fixation. Various plug designs are used to increase pressure. No data is available on their ability to occlude the canal. Factors including canal size, canal shape and cement viscosity may affect performance. The two aims of this study are (I) to determine the effect of cement viscosity, canal shape and canal size on the ability of cement restrictors to withstand cementation pressures, and (II) to determine which of the currently commercially available designs of cement restrictor is able to withstand cementation pressures, regardless of values of other potentially influential factors. Methods: Artificial femoral canals were drilled in oak blocks. Circular canals had diameters of 12 or 17.5 mm. Oval canals had short axes equal to the diameter of the circular canals and long axes 1.3 times longer. This ellipticity of 1.3 is average for human femoral canals. One of four types of cement plugs (Hardinge, DePuy, UK; Exeter, Stryker, UK; Amber Flex, Summit Medical, UK; and OptiPlug, Scandimed, Sweden) was inserted. A pressure transducer was fitted in the canal just proximal to the plug. Bone cement (Palacos LV-40 low viscosity or Palacos R-20 high viscosity, both Schering Plough, UK) was prepared in a mixing device for 1 min at 21°C, and inserted in the artificial canal after 4 minutes. A materials testing machine was used to generate pressure in the cement. Cement pressure and plug position were measured. All combinations of canal size and shape, plug design and cement viscosity were pre-selected according to a D-optimal experimental design which was optimised to perform a four-way ANOVA to analyse the four main factors plus the interactions between plugs and the other three factors. A total of 23 experiments was performed. Results: Average cement pressures achieved differed between implants (OptiPlug 448±66 kPa, Hardinge 142±66, Exeter 705±66, Amber Flex 475±72; p=0.002, all mean±SEM). They also differed between canal sizes (12 mm 529±49, 18 mm 356±47; p=0.03), canal shapes (Round 631±45, Oval 254±51; p=0.004) and cement viscosity (High 535±54, Low 350±43; p=0.03). No significant interaction between factors was found. Discussion and Conclusion: All plugs resisted lower pressures in large canals, oval canals or with low viscosity cement. When comparing plugs, these different circumstances should therefore be taken into account. Of the four tested, the Exeter plug performed best in all adverse circumstances. The OptiPlug and AmberFlex, which are both resorbable, had an intermediate performance. The Hardinge plug performed worse

Multiple studies have established an inverse relationship between ambient theatre temperatures and polymethyl methacrylate (PMMA) cement setting times. It is also known that allowing cement to equilibrate to ambient theatre temperatures restores expected setting characteristics. One overlooked entity is the transport and storage conditions of cement. This is important in tropical regions, where extreme temperature and humidity may cause rapid cement setting times, resulting in potentially significant intra-operative complications. This study investigated the relationship between extreme transport and storage conditions of Antibiotic Simplex cement (Stryker), and the effect on setting times at Cairns Hospital, Far North Queensland, Australia. Fifty units of cement were divided evenly into a control arm and four experimental arms. The experimental arms were designed to mimic potential transport and storage conditions. They included seven days of storage in a medication fridge, on the hospital loading dock, in a cane shed, and in a Toyota Landcruiser parked outdoors during January 2022. Humidity and temperature readings were recorded. The samples in each group were evenly distributed to equilibrate to theatre conditions for 1 hour and 24 hours. Setting time was recorded when a no. 15 scalpel blade was unable to mark the surface. All three ‘hot’ exposures setting times were significantly faster for both 1 hour (ρ=0.001) and 24 hours (ρ=0.024) equilibration times. The difference in setting times for the ‘cold’ exposure was not significant for either equilibration times (ρ=1). To our knowledge, this is the first study investigating cement setting times in tropical climates. Further studies are required to address the effect of these conditions on biomechanical strength of PMMA cement. We conclude that extreme heat and humidity during transport and storage have a statistically significant effect on cement setting times

Aim. Galleria mellonella larvae is a well-known insect infection model that has been used to test the virulence of bacterial and fungal strains as well as for the high throughput screening of antimicrobial compounds against infections. Recently, we have developed insect infection model G. mellonella larvae to study implant associated biofilm infections using small K-wire as implant material. Here, we aimed to further expand the use of G. mellonella to test other materials such as bone cement with combination of gentamicin to treat implant-associated infections. Method. The poly methyl methacrylate (PMMA) with and without gentamicin and liquid methyl methacrylate (MMA) were kindly provided by Heraeus Medical GmbH, Wehrheim. To make the bone cement implants as cubes, Teflon plate (Karl Lettenbauer, Erlangen) with specified well size was used. The Radiopaque polymer and monomer were mixed well in a bowl, applied over on to the Teflon plate and pressed with spatula to form fine and uniform cubes. After polymerization, the bone cement implants were taken out of the Teflon well plate with the help of pin. For the infection process, bone cement cubes were pre-incubated with S. aureus EDCC 5055 culture at 5×10. 6. CFU/ml for 30 min at 150 rpm shaking conditions. Later, these implants were washed with 10ml PBS and implanted in the larvae as mentioned. Survival of the larvae were observed at 37°C in an incubator. To analyze the susceptibility of the bacterial infections towards gentamicin, survival of the larvae compared with control group implanted only with bone cement. The effect of gentamicin was also measured in terms of S. aureus load in larvae on 2. nd. day. SEM analysis was performed to see the effect of gentamicin on biofilm formation on bone cement. Results. Our experiments established the G. mellonella as an excellent model to screen bone cement with antimicrobial compounds against bacterial infections. The gentamicin bone cement samples showed excellent S. aureus bacterial load reduction after the implantation in G. mellonella model. The bone cement with gentamicin showed better survival of larvae infected with S. aureus compared to control. Finally, the gentamicin also affected the biofilm formation on the bone cement surface with S. aureus. Conclusions. Thus, our work showed G. mellonella is a rapid, cheap economical pre-clinical model to study the bone cement associate bacterial infections as well as screening of the various antimicrobial compounds

Aim: Cementation of tibial implants in total knee arthroplasty is a gold-standard considering the high loosening rates of cementless implants. In contrast, only sparse data exist regarding unicondylar arthroplasty due to limited use. In this study, we compare cemented with cementless unicondylar knee arthroplasty and aim to define both clinical and radiological differences in treatment outcome. Materials and Methods: In a retrospective study, 106 patients who had undergone a medial unicondylar replacement were examined after a mean postoperative period of 8 years. Of these, 42 patients (median age 81±7 years) had received a cemented and 64 (median age 73±7 years) a cementless knee arthroplasty by the same surgeon while 7 patients were deceased or could not be reached. Well-established clinical (VAS, HSS, KSS, UCLA, WOMAC) and quality of life (SF-36) scores were used to evaluate treatment outcome. X-rays were performed to evaluate periprosthetic loosening zones, according to Ewald’s criteria. Results: The cementless patient group presented significantly better clinical scores (HSS, KSS, UCLA, WOMAC), except in the Visual Analogue Scale (VAS) for pain assessment. The quality of life was significantly better in the cementless group except in the subgroups concerning physical function, vitality and social role, which resembled normal population. Moreover, radiographic analysis using antero-posterior X-rays revealed significantly more and larger periprosthetic loosening areas in tibial zone 2 in the cementless group. Conclusion: The inferior clinical results characterising the cemented group could be attributed to the higher mean age. Regarding the radiological loosening zones, we did not detect any differences in the techniques of fixation, although physical activity and mechanical stresses were higher in the cementless group

Primary hip and knee joint replacements in Canada have been estimated to cost over $1.4 billion dollars annually, with revision surgery costing $177 million. The most common cause of revision arthroplasty surgery in Canada is infection. Periprosthetic joint infections (PJIs) are a devastating though preventable complication following arthroplasty. Though variably used, antibiotic laden bone cement (ALBC) has been demonstrated to decrease PJIs following primary total knee arthroplasty (TKA). Unfortunately, ALBC is costlier than regular bone cement (RBC). Therefore, the aim of this study was to determine if the routine use of ALBC in primary TKA surgery is a cost-effective practice from the perspective of the Canadian healthcare system. A decision tree was constructed using a decision analysis software (TreeAge Software, Williamstown, Massachusetts) to a two-year time horizon comparing primary TKA with either ALBC or RBC from the perspective of a single-payer healthcare system. All costs were in 2020 Canadian dollars. Health utilities were in the form of quality adjusted life years (QALYs). Model inputs for cost were derived from regional and national databases. Health utilities and probability parameters were derived from the latest literature. One-way deterministic sensitivity analysis was performed on all model parameters. The primary outcome of this analysis was an incremental cost-effectiveness ratio (ICER) with a willingness-to-pay (WTP) threshold of $50,000 per QALY. Primary TKA with ALBC (TKA-ALBC) was found to be more cost-effective compared to primary TKA with RBC (TKA-RBC). More specifically, TKA-ALBC dominated TKA-RBC as it was less costly on the long term ($11,160 vs. $11,118), while providing the same QALY (1.66). The ICER of this cost-utility analysis (CUA) was $-11,049.72 per QALY, much less than the WTP threshold of $50,000 per QALY. The model was sensitive to costs of ALBC-TKA as well as the probability of PJI following ALBC-TKA and RBC-TKA. ALBC ceased to be cost effective once the cost of ALBC was greater than $223.08 CAD per bag of cement. The routine use of ALBC in primary TKA is a cost-effective practice in the context of the Canadian healthcare system as long as the cost of ALBC is maintained at a reasonable price and the published studies to-date keep supporting the efficacy of ALBC in decreasing PJI following primary TKA. Further, this analysis is very conservative, and ALBC is likely much more cost-effective than presented. This is due to this model's revision surgery cost parameter being based on the average cost of all revision TKA surgery in Canada, regardless of etiology. Considering many PJIs require two-stage revisions, the cost parameter used in this analysis for revision surgery is an underestimate of true cost. Ultimately, this is the first cost-effectiveness study evaluating this topic from the perspective of the Canadian healthcare system and can inform future national guidelines on the subject matter

This study aimed to analyze the effect of two different techniques of cement application: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term effect of radiolucent lines (RLL) in primary fully cemented total knee arthroplasties (TKA) with patella resurfacing. 379 fully cemented TKAs (318 patients) were included in this monocentric study. Preoperative and postoperative at week 4 and 12 month after surgery all patients had a clinical and radiological examination and were administered the Oxford Knee Score (OKS). Cement was applied in two different ways among the two study groups: cement on bone surface (CoB group) or cement on bone surface and implant surface (CoBaI group). The evaluation of the presence of RLL or osteolysis was done as previously described using the updated Knee Society Radiographic Evaluation System. The mean OKS and range of motion improved significantly in both groups at the 4-week and 12-month follow-up, with no significant difference between the groups (CoB vs. CoBaI). RLL were present in 4.7% in the whole study population and were significantly higher in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up RLL were seen in 29.8% of the TKAs in the CoBaI group, whereas the incidence was lower in the CoB group (24.0% (n.s.)). There were two revisions in each group. None of these due to aseptic loosening. Our study indicated that the application of bone cement on bone surface only might be more beneficial than onto the bone surface and onto the implant surface as well in respect to the short-term presence of RLL in fully cemented primary TKA. The long-term results will be of interest, especially in respect to aseptic loosening and might guide future directions of bone cement applications in TKA

According to the latest report from the German Arthroplasty Registry, aseptic loosening is the primary cause of implant failure following primary hip arthroplasty. Osteolysis of the proximal femur due to the stress-shielding of the bone by the implant causes loss of fixation of the proximal femoral stem, while the distal stem remains fixed. Removing a fixed stem is a challenging process. Current removal methods rely on manual tools such as chisels, burrs, osteotomes, drills and mills, which pose the risk of bone fracture and cortical perforation. Others such as ultrasound and laser, generate temperatures that could cause thermal injury to the surrounding tissues and bone. It is crucial to develop techniques that preserve the host bone, as its quality after implant removal affects the outcome of a revision surgery. A gentler removal method based on the transcutaneous heating of the implant by induction is proposed. By reaching the glass transition temperature (T. G. ) of the periprosthetic cement, the cement is expected to soften, enabling the implant to be gently pulled out. The in-vivo environment comprises body fluids and elevated temperatures, which deteriorate the inherent mechanical properties of bone cement, including its T. G. We aimed to investigate the effect of fluid absorption on the T. G. (ASTM E2716-09) and Vicat softening temperature (VST) (ISO 306) of Palacos R cement (Heraeus Medical GmbH) when dry and after storage in Ringer's solution for up to 8 weeks. Samples stored in Ringer's solution exhibited lower T. G. and VST than those stored in air. After 8 weeks, the T. G. decreased from 95.2°C to 81.5°C in the Ringer's group, while the VST decreased from 104.4°C to 91.9°C. These findings will be useful in the ultimate goal of this project which is to design an induction-based system for implant removal. Acknowledgements: Funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) – SFB/TRR-298-SIIRI – Project-ID 426335750

Retention of well fixed bone cement at the time of a revision THA is an attractive proposition, as its removal can be difficult, time consuming and may result in extensive bone stock loss or fracture. Previously reported poor results of cemented revision THA, however, have tended to discourage Surgeons from performing “cement in cement” revisions, and this technique is not in widespread use. Since 1989, we have performed a cement within cement femoral stem revision on 354 occasions. The indications for in cement revision included facilitating acetabular revision, replacement of a monoblock stem with a damaged or incompatible head, revision of hemiarthroplasty to THA, component malposition and broken stem. Cement in cement revision was only performed in the presence of well fixed cement with an intact bone-cement interface. An Exeter polished tapered stem was cemented into the existing cement mantle on each occasion. Follow up of 5 years or longer is available for 175 cases, and over 8 years in 41. On no occasion has a cement in cement femoral stem had to be re-revised during this time for subsequent aseptic loosening. Advantages include preservation of bone stock, reduced operating time, improved acetabular exposure and early post operative full weight bearing mobilisation. This technique has not been used for 1 stage revision of infection. This experience has encouraged the refinement of this technique, including the development of a new short stem designed specifically for cement within cement revisions. This stem is designed to fit into an existing well fixed cement mantle of most designs of cemented femoral component or hemi-arthroplasty, with only limited preparation of the proximal mantle required. The new stem greatly simplifies cement in cement revision and minimises the risk of distal shaft perforation or fracture, which is otherwise a potential hazard when reaming out distal cement to accommodate a longer prosthesis

Retention of well fixed bone cement at the time of a revision THA is an attractive proposition, as its removal can be difficult, time consuming and may result in extensive bone stock loss or fracture. Previously reported poor results of cemented revision THA, however, have tended to discourage Surgeons from performing ‘cement in cement’ revisions, and this technique is not in widespread use. Since 1989 in Exeter, we have performed a ‘cement within cement’ femoral stem revision on 354 occasions. An Exeter polished tapered stem has been cemented into the existing cement mantle on each occasion. Clinical and radiological follow up of 5 years or longer is available for 156 cases. On no occasion has a cement in cement femoral stem had to be re-revised during this time for subsequent aseptic loosening. This has encouraged the refinement of this technique, including the development of a new short stem designed specifically for cement within cement revisions. This stem is designed to fit into an existing well fixed cement mantle of most designs of cemented femoral components or hemi-arthroplasties, with only limited preparation of the proximal mantle required. The new stem greatly simplifies cement in cement revision and minimises the risk of distal shaft perforation or fracture, which is otherwise a potential hazard when reaming out distal cement to accommodate a longer prosthesis

Introduction. Cement in cement revision with preservation of the original cement mantle has become an attractive and commonly practised technique in revision hip surgery. Since introducing this technique to our unit we have used two types of polished tapered stem. We report the clinical and radiological outcomes for cement in cement femoral revisions performed using these prostheses. Materials and Methods. All patients who underwent femoral cement in cement revision with a smooth tapered stem between 2005 –2013 were assessed. Data collected included indication for revision surgery and components used. All patients were followed up annually. Outcomes recorded were radiographic analysis, clinical outcome scores (Oxford Hip Score, WOMAC and SF-12) and complications, including requirement for further revision surgery. Median follow-up was 5 years (range 1 – 8 years). 116 revision procedures utilising cement in cement femoral revision were performed in the 8 year study period (68 females, 48 males, and mean age of 69 years). The femoral component was a C-stem AMT (Depuy) in 59 cases and Exeter stem (Stryker) in 57 cases. Results. Radiographic analysis demonstrated no progressive radiolucencies around the femoral component in any patient and no evidence of stem loosening at most recent review. Median Oxford Hip Score increased from 15 to 32, WOMAC from 22 to 38, and SF-12 from 25 to 32. Two patients had a further revision procedure for recurrent dislocation and 1 patient for infection. Two patients had a peri-prosthetic fracture at 4 years following initial revision surgery. There were 2 femoral stem fractures (occurring at 3 and 4 years post revision, both occurring in Exeter stems). Conclusion. Our results report cement in cement revision of the femoral component provides promising mid-term radiographic and clinical results. No femoral stems required revision for aseptic loosening. Stem fracture however occurred in 2 cases suggesting stem design is crucial for this technique

Background. Antibiotic loaded bone cement (ALBC) is commonly used in cemented total hip arthroplasty (THA) in an attempt to reduce the risk of prosthetic joint infection (PJI). However, its role versus plain cement remains controversial due to the potential risk of developing resistant organisms and potential excess costs incurred from its usage. We investigated the relationship of ALBC and plain cement in affecting outcome of revision surgery after primary THA. Methodology. We conducted a retrospective study of data collected from National Joint Registry for England and Wales, Northern Ireland and the Isle of Man between 1. st. September 2005 until 31. st. August 2017. A logistic regression analysis model was used to investigate the association between ALBC versus plain cement and the odds ratio (OR) for revision, adjusting for age, ASA grade, bearing surfaces, head size and cup and stem fixation. Indications for revision recorded in NJR were considered in separate models. Results. We identified 418,925 THAs where bone cements were used (22,037 plain cement; 396,888 ALBC). After adjusting for confounding factors, the risk of revision for infection was lower with ALBC (OR 0.77, 95% CI 0.62–0.95). There was also lower risk of revision for aseptic loosening of stem (OR 0.53, 95% CI 0.39–0.72), aseptic loosening of socket (OR 0.46, 95% CI 0.37– 0.58). When breaking down hips into fully cemented or hybrid fixation, the protective effect of ALBC against infection was only apparent in fully cemented (OR 0.65, 95% CI 0.48–0.87) when compared against hybrid fixation (OR 0.90, 95% CI 0.66–1.23). Discussion. Within the limits of registry analysis, this study has demonstrated an association between the use of ALBC and lower rates of revision for infection and aseptic loosening. Conclusion. This finding supports the current use of ABLC in cemented THAs

In revision hip surgery, a solidly cemented femoral component may obstruct access to the acetabulum, may be poorly orientated, or may have inadequate offset and head diameter. These problems can be addressed by revising the femoral component. The object of this study was to determine the outcome of cementing a polished, tapered, modular implant into the retained cement mantle. Benefits of cement within cement revision of a femoral stem include simplicity, reduced theatre time, and potentially reduced complication rates. A consecutive series of 36 patients (11 men, 25 women) age range 35 to 90 years (mean age 70) underwent c stem cement in cement revision hip arthroplasty between June 2000 and April 2006. Indications for revision arthroplasty included 20 patients with aseptic acetabular loosening and 13 patients with recurrent instability. Follow up (12–84 months, mean 48 months) was annual and the outcome for every implant was known. Outcome measures included the shortened WOMAC score, Orthowave patient satisfaction survey, radiographic analysis, and assessment of the records for perioperative complications. No patients were lost to follow up, 2 patients died with their hip in situ. The mean post operative WOMAC score at latest follow up was 10.89 (median 11, range 0 to 29). There has been no clinical or radiological signs of prosthesis loosening or failure on follow up. Complications included: one sacral plexus palsy which had a partial recovery, and one intra-operative periprosthetic fracture identified and treated at the time of the revision procedure. One patient underwent a further cup revision for recurrent dislocation. Cement within cement revision hip arthroplasty using a highly polished tapered stem in the short to medium term provides satisfactory functional outcomes and is associated with low complication rates and good survivorship. Longer term results are awaited

Introduction and Objective. The continued effectiveness of antibiotic loaded bone cements is threatened by antibiotic resistance. The common antiseptic, chlorhexidine (CHX), is a potential alternative to antibiotics in bone cements, but conventional salts are highly soluble, causing burst release and rapid decline to subinhibitory local CHX concentrations. Here, chlorhexidine triphosphate (CHX-TP), a low solubility CHX salt, is investigated as an alternative antimicrobial in PMMA bone cements. The aim was to assess duration of antimicrobial release and antimicrobial efficacy, along with handling, setting and mechanical properties of CHX-TP loaded cements, compared with an existing cement formulation containing gentamicin. Materials and Methods. Palacos R (Heraeus Medical, Newbury, UK) with 0, 1, 4, 7 and 12% CHX-TP (w/w) cements were prepared by combining solid CHX-TP with Palacos R components, and compared with Palacos R+G. All cements were prepared without vacuum and under ISO 5833:2002 conditions. Cements were tested under ISO 5833:2002 for compressive and bending properties, setting time, maximum temperature and doughing time. Antimicrobial release from the cements into deionised water was studied and antimicrobial efficacy of unaged and aged cements against Staphylococcus aureus (ATCC 29213) was assessed using a disc diffusion assay. Results. Compressive strength of CHX-TP loaded cements was not significantly different to Palacos R or Palacos R+G (p > 0.05, all exceeding ISO 5833:2002 minimum of 70 MPa). Mean bending strength was significantly lower with CHX-TP loading (p < 0.05) than bending strength of Palacos R and Palacos R+G, though all bending moduli exceeded the ISO 5833:2002 minimum (1800 MPa). All cements studied were within the ISO 5833:2002 limits for setting time (3 to 15 min), doughing time (≤ 5 min) and maximum temperature (90 . o. C). Mean doughing time for Palacos R, Palacos R+G and Palacos R + 12 % CHX-TP respectively: 52.5 s, 45 s and 45 s. Mean setting time and mean maximum temperature for Palacos R, Palacos R+G and Palacos R + 1, 4, 7 and 12% CHX-TP respectively: 11.00 min (73 . o. C), 11.25 min (72 . o. C), 12.25 min (66 . o. C), 10.50 min (70 . o. C), 10.00 min (70 . o. C), 10.75 min (62 . o. C). Sustained CHX release into deionised water was observed from all Palacos R + CHX-TP cements. Duration varied according to CHX-TP dosing and diminished over time, although to an extent that itself varied with dosing. 1 % CHX-TP ceased releasing CHX at 6.9 weeks; 4 % CHX-TP ceased at 67.7 weeks; 7 % and 12 % CHX-TP were ongoing at 75.5 weeks. Palacos R+G cements ceased releasing detectable levels of gentamicin after 14.4 weeks. Palacos R+G and Palacos R + CHX-TP cement discs showed efficacy against S. aureus (ATCC 29213) when applied as prepared (unaged) to S. aureus bacterial lawns in disc diffusion assays, with CHX-TP cements showing dose dependency. Zone of inhibition (ZOI) size was significantly reduced for Palacos R+G cements and Palacos R + 1% CHX-TP cements after 1 week and 6 weeks aging, compared to ZOI from unaged cements (p < 0.05). ZOI size produced by Palacos R + 4, 7, and 12 % CHX-TP cements did not decline significantly after 6 weeks aging (p > 0.05). Conclusions. CHX-TP can be incorporated into the Palacos R cement matrix up to 12% w/w without deterioration of compressive strength, bending modulus, doughing time, setting time or maximum temperature. Bending strength was significantly reduced at all CHX-TP loadings studied. Palacos R + 4, 7 and 12% CHX-TP cements provided sustained CHX release, exceeding the duration of gentamicin release from Palacos R+G, and showed sustained efficacy against S. Aureus after 6 weeks aging, which was not achieved by Palacos R+G cements

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

Introduction. In cemented total hip arthroplasty (THA), proper cement mantle thickness in the femoral canal is still controversial subject. It is widely accepted that the cement mantle around a femoral stem should be at least 2 mm in thickness. But articles from France reported good long-term result with thin cement mantle. It is so called “The French paradox”. We have already reported that the greater compressive force at the cement-bone interface was seen in collarless polished tapered (CPT, Zimmer, USA) stem with thick cement mantle than that with thin cement mantle. However, the stem with thick cement mantle subsided more than with thin mantle. It may have a possibility to cause an early mechanical failure of cemented THA. We compared to stem and cement subsidence in various cement mantles using tantalum ball into cement in this study. Methods. A cemented stem model was used for this study with a CPT stem into composite femur. Three sizes of CPT stems (No. 1, No. 2 and No. 3) and one size composite femur were prepared for this study. We inserted two stems for each size, for a total of six stems. Composite femurs were reamed with a No. 3 rasp, and various size of stem was fixed with cement in each composite femur to make a various thicknesses of cement mantle. Two to three tantalum marker balls were injected into the cement in each femur before cement was hardened. 1-Hz dynamic load applied to the stems for half a-million cycles. Each 16 hours of loading was followed by 8 hours without loading. We used micro-CT before and after loading to measure the movement of the tantalum balls in three dimensions. And we analyzed occupation ratio of stem in the femoral canal by computed reconstructed three dimensional model of bone cement and stem. Results. We were able to detect a total of 13 balls in the cement for the 6 stems. The range of cement thickness in the CT slice on balls was 1.52 to 5.32 mm. Stem subsidence showed a significantly positive correlation to the thickness of cement mantle. In the horizontal plane, 8 of these 13 balls moved in an outside direction and five moved in an inside direction. The horizontal/perpendicular ratio for the tantalum balls showed a significant negative correlation to the thickness of the cement mantle. The subsidence rate (ratio of stem subsidence to ball subsistence) showed a significant negative correlation to the stem occupation ratio. The effective radial cement creep was also detected when the cement mantle was less than 2.5 mm thick and more than 60% in the occupation ratio. Conclusions. Stem subsistence was more commonly associated with cement subsidence in the thicker cement mantles and with a low stem occupation rate in CPT stems

Aim: To study the influence of cement restrictors on the thickness and quality of femoral cement mantle. Methods: In this prospective study, there are 49 cases of Hardinge restrictor and 33 cases bone block restrictor were used for Charnley hip replacement. The operation was carried out by one surgeon on 78 patients between 1 March 2003 and 30th April 2004. Each preoperative X-rays were templated for the placement of restrictor. Intraoperatively, a calibrated holder for the cement restrictor was used aiming at keeping the distal cement height within 2-3 cm of the tip of the femoral prosthesis. Postoperative X-rays were checked for cement mantle thickness and quality. Results: The preoperative target of having a distal cement height of 2-3 cm was achieved as seen on postoperative X-ray in only 60.6% of the bone block group and 30.6% of the Hardinge group. Distal migration of the restrictors was associated with non-homogenous cement mantle in zones 3, 4 and 5 but did nor affect zone 2, 6, or7. As the restrictor remained within 20-30 mm, the thickness of mantle is maintained between 9mm and 21mm in zone 4. This finding is statistically significant with the p value of 0.001. Conclusion: Though the bone block was marginally better than Hardinge restrictor, we conclude that the current available cement restrictors are not sufficiently good enough to offer a good cavity for cement intrusion in to the bone; further restrictors need to be developed and tested before clinical use

Introduction. While fixation on the acetabular side in resurfacing implants has been uncemented, the femoral component is usually cemented. The most common causes for early revision in hip resurfacing are femoral head and or neck fractures and aseptic loosening of the femoral component. Later failures appear to be more related to adverse soft-tissue reactions due to metal wear. Little is known about the effect of cementing techniques on the clinical outcome in hip resurfacing, since retrieval analysis of failed hip resurfacing show large variations. Two cementing techniques have dominated. The indirect low viscosity (LV) technique as for the Birmingham Hip resurfacing (BHR) system and the direct high viscosity (HV) technique as for the Articular Surface replacement (ASR) system. The ASR was withdrawn from the market in 2010 due to inferior short and midterm clinical outcome. This study presents an in vitro experiment on the cement mantle parameters and penetration into ASR resurfaced femoral heads comparing both techniques. Methods. Five sets of paried frozen cadavar femura (3 male, 2 female) were used in the study. The study was approved by ethics committee. Plastic ASR replicas (DePuy, Leeds, UK), femoral head size 47Ø were used. The LV technique was used for the right femora (Group A, fig. 1 and 3) while the HV technigue was used for the left femora (Group B. Fig 2 and 4). The speciments were cut into quadrants. An initiial visual, qualitative evaluation was followed by CT analysis of cement mantle thickness and cement penetration into bone. Results. No significant differences were seen between the four quadrants within each group. The LV technigue resulted in greater cement penetration and increased cement mantle under the top proximally. The HV technique showed less penetration and lower cement mantle. See figures 1–4. Discussion. The aim was to analyze the effect of the cementing techniques used in hip resurfacing practice. The ASR implant was chosen to improve understanding of whether the implant may have been sensitive to cementing techniques and whether an analysis of cementing with the recommended HV technique may assist in explaning the high incidence of short-term ASR revisions due to fractures. Findings for the HV technigue would indicate a superior technique according to consensus in conventional arthropalsty However, this contradicts clinical evidence on resurfacing, where LV cementation has been shown tho be superior. The superficial intergration in the HV technigue may result in only a superficial integration and subsequently suboptimal fixation to bone. To view tables/figures, please contact authors directly

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