We reviewed 44 consecutive revision hip replacements in 38 patients performed using the cement-in-cement technique. All were performed for acetabular loosening in the presence of a well-fixed femoral component. The mean follow-up was 5.1 years (2 to 10.1). Radiological analysis at final follow-up indicated no loosening of the femoral component, except for one case with a continuous radiolucent line in all zones and peri-prosthetic fracture which required further revision. Peri-operative complications included nine proximal femoral fractures (20.4%) and perforation of the proximal femur in one hip. In five hips wiring or fixation with a braided suture was undertaken but no additional augmentation was required. There was an improvement in the mean Japanese Orthopaedic Association score from 55.5 (28 to 81) pre-operatively to 77.8 (40 to 95) at final follow-up (p < 0.001). Revision using a cement-in-cement technique allows increased exposure for acetabular revision and is effective in the medium term. Further follow-up is required to assess the long-term results in the light of in vitro studies which have questioned the quality of the cement-in-cement bond

Aims. We report the incidence of radiolucent lines (RLLs) using two flanged acetabular components at total hip arthroplasty (THA) and the effect of the Rim Cutter. Patients and Methods. We performed a retrospective review of 300 hips in 292 patients who underwent primary cemented THA. A contemporary flanged acetabular component was used with (group 1) and without (group 2) the use of the Rim Cutter and the Rimfit acetabular component was used with the Rim Cutter (group 3). RLLs and clinical outcomes were evaluated immediately post-operatively and at five years post-operatively. Results. There was no significant difference in the incidence of RLLs on the immediate post-operative radiographs (p = 0.241) or at five years post-operatively (p = 0.463). RLLs were seen on the immediate post-operative radiograph in 2% of hips in group 1, in 5% in group 2 and in 7% in group 3. Five years post-operatively, there were RLLs in 42% of hips in group 1, 41% in group 2 and in 49% in group 3. In the vast majority of hips, in each group, the RLL was present in DeLee and Charnley zone 1 only (86%, 83%, 67% respectively). Oxford and Harris Hip scores improved significantly in all groups. There was no significant difference in these scores or in the change in scores between the groups, with follow-up. Conclusion. Despite the Rim Cutter showing promising results in early laboratory and clinical studies, this analysis of the radiological and clinical outcome five years post-operatively does not show any advantage over and above modern cementing techniques in combination with a well performing cemented acetabular component. For this reason, we no longer use the Rim Cutter in routine primary THA. . Cite this article: Bone Joint J 2017;99-B:1450–7

Revision of a cemented hemiarthroplasty of the hip may be a hazardous procedure with high rates of intra-operative complications. Removing well-fixed cement is time consuming and risks damaging already weak bone or perforating the femoral shaft. The cement-in-cement method avoids removal of intact cement and has shown good results when used for revision total hip arthroplasty (THA). The use of this technique for the revision of a hemiarthroplasty to THA has not been previously reported. A total of 28 consecutive hemiarthroplasties (in 28 patients) were revised to a THA using an Exeter stem and the cement-in-cement technique. There were four men and 24 women; their mean age was 80 years (35 to 93). Clinical and radiographic data, as well as operative notes, were collected prospectively and no patient was lost to follow-up. Four patients died within two years of surgery. The mean follow up of the remainder was 70 months (25 to 124). Intra-operatively there was one proximal perforation, one crack of the femoral calcar and one acetabular fracture. No femoral components have required subsequent revision for aseptic loosening or are radiologically loose. . Four patients with late complications (14%) have since undergone surgery (two for a peri-prosthetic fracture, and one each for deep infection and recurrent dislocation) resulting in an overall major rate of complication of 35.7%. The cement-in-cement technique provides reliable femoral fixation in this elderly population and may reduce operating time and rates of complication. Cite this article: Bone Joint J 2015;97-B:1623–7

We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt > 5° or subsidence > 5 mm), the presence of radiolucent lines and a Constant score of < 30 as the endpoints. There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of > 30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001). We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement

One of the drawbacks of cemented total hip arthroplasty (THA) is aseptic loosening after long period, major reason for which is bioinertness of PMMA bone cement. To improve longevity of THA, interface bio-active bone cement technique combined with modern cementing technique has been used in our institute, and was evaluated clinically and radiologically. The present study includes 44 cases of primary THA with an average age at operation of 64 years old (ranging 48 to 81). Mean postoperative follow up period was 4 (ranging 3.5 to 5) years. Pre- and postoperative evaluation using Merle d’Aubigné score were 8.0 and 16.2 points, respectively. Postoperative cementing grade using Barrack’s classification was A or B. At final follow up, radiolucent line at bone-cement interface was not observed, except one case of rheumatoid arthritis patient at zone 3 described by Delee and Charnley in the acetabular side. Neither osteolysis nor loosening was observed in every case. No major complications, such as infection, dislocation, pulmonary embolization, were observed. The present study revealed excellent short-term result was obtained by IBBC technique combined with modern cementing technique for primary THAs. Most important technical point required for IBBC is to obtain dry bony surface just before cementing. Compressive reamed bone and gauze packing was effective for complete hemostasis just before cementing for the acetabular side, and plugging the isthmus using bone chips was effective for reducing bleeding for the femoral side

Aim. To compare radiological and clinical outcomes between triceps-detaching and triceps-sparing approaches in total elbow arthroplasty, with specific focus on cementing technique and post-operative range of motion. Methods. A retrospective review was completed of medical records and radiographs of 56 consecutively managed patients who underwent a primary total elbow arthroplasty between 2000 and 2012 at a tertiary hospital. Rheumatoid Arthritis was the predominant pathology (47/56). Data analysed included patient demographics, range of motion pre-operatively and at various stages post-operatively, approach utilized, operative time and complications. Cementing technique was graded as adequate, marginal or inadequate according to Morrey's criteria. Results. 12 patients were lost to follow-up or had incomplete records, leaving 44 patients for analysis. 15 patients had a triceps-sparing approach, and 29 had a variation of a triceps-detaching approach. Average follow-up was 56.1 months. Flexion range of motion in the triceps-sparing group improved from 25°–122° (±19.6°) pre-op to 10°–140° (±22.5°) at final follow-up, and in the triceps-detaching group from 41°–104° (± 22.2°) pre-op to 27°–129° (±35.0°) at final follow-up. Tourniquet time averaged 85.4 (±17.0) minutes for the triceps-sparing group and 96.1 (±22.6) minutes for the triceps-detaching group. The complication rate in the triceps-sparing group was 13.3%, and included one olecranon fracture and one case of superficial wound sepsis. The complication rate for the triceps-detaching group was 24.1%, and included one patient with persistent ulnar nerve symptoms requiring transposition, one medial condyle fracture and five triceps ruptures. Three patients who had attempted repairs of the rupture developed deep infections requiring multiple further surgeries. Cementing technique was adequate in 91.7% in the triceps-sparing group and in 70.6% in the triceps-detaching group and marginal in the remainder of the cohort. Conclusion. A triceps-sparing approach results in a predictable improvement in range of motion with no compromise of the cement mantle. NO DISCLOSURES

There exists a lot literature referring to the cementing technique of hip replacements, but when talking about longevity of knee prostheses only seldom the cementing technique is mentioned even though 90% of the knees are cemented. Especially the tibial component, that has to cope with different forces such as pressure, rotation, tilt and sliding, is said to last longer when cemented. Cementing Technique: There are many aspects that need to be thought of when cementing knee prostheses:. The preparation of the bone: The preparation of the surface of the bone is of great importance, as the-bond of the cement with the bone is by the shape of the surfaces and not by a chemical reaction. A good penetration of the cement into the cancellous-bone enlarges the connecting surface and optimizes the power transmission. The pulse-lavage is the most effective to open the spongy bone. Sclerotic bone needs to be penetrated. Selection of cement: PMMA-cement (Polymeth-ylmetacrylat) is used with proven effectiveness since 1958 (Charnley). Very Similar to the well known cement Palacos (BiometMerck) is the new SmartSet GHV (DePuy) but it provides a longer time for processing, which is useful when cementing all components in one go. Mixing and hardening time are therefore shorter. Mixing of the cement: Mixing is mostly done manually even though it is known that the quality of the cement is minor than with a vacuum system. The advances of such a system are better microporosity, no air bubbles, and safety for the staff, who breathe less fumes. Application of cement – viscosity: The cement can be applied to the prosthesis or directly onto the bone. If the implant is precoated, the viscosity of the cement should be low to achieve better joint. The bone should in any case be dry to avoid mixing with blood. Pressure: During implantation a short high pressure is of importance for the depth of penetration. Some implants have an edge to guarantee better distribution of the pressure. During the hardening of the cement the pressure has to b ekept at a certain level as the volume of the cement changes a bit during the polimerisation. Hardening: The pressure needs to be controlled avoiding small movements. When cementing all components at once the ligaments have to be balanced, otherwise unnoticed deviations might occur. The leg should not be hyperextended to avoid tilting of the components. Temperature of polimerisation: The temperature can be reduced in vivo by cooling of the bone or the cement and by good spongy bone that transports the temperature away. If the cement penetrates more than 5 mm or its homogeneous thickness is more than 3mm osteonecrosis is likely to occur. Thickness of cement layer: Several authors and the finite element measurements found out, that acement layer from 2–5 mm ensures good stability for the tibial component. Cementing the shaft does not lead to significant better results but may lead to atrophy of the bone underneath the tibial plateau. Femoral components show good results also uncemented. Excess of cement: Cement that juts out must be removed especially in the dorsal parts, where an impingement can be produced. Bits in the soft tissue must also be removed with care. Cement should not touch the polyethylene during the whole procedure. Antibiotics: The quality and longevity of the cement is reduced by adding antibiotics because of resulting higher porosity. A special management for risk patientsis necessary. When cementing knee prostheses one should give high attention to the cementing technique as especially a good anchorage of the tibial component will lead to longevity of the implant

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.

The removal of well-fixed bone cement from the femoral canal during revision of a total hip replacement (THR) can be difficult and risks the loss of excessive bone stock and perforation or fracture of the femoral shaft. Retaining the cement mantle is attractive, yet the technique of cement-in-cement revision is not widely practised. We have used this procedure at our hospital since 1989. The stems were removed to gain a better exposure for acetabular revision, to alter version or leg length, or for component incompatibility.

We studied 136 hips in 134 patients and followed them up for a mean of eight years (5 to 15). A further revision was required in 35 hips (25.7%), for acetabular loosening in 26 (19.1%), sepsis in four, instability in three, femoral fracture in one and stem fracture in one. No femoral stem needed to be re-revised for aseptic loosening.

A cement-in-cement revision of the femoral stem is a reliable technique in the medium term. It also reduces the risk of perforation or fracture of the femoral shaft.

The optimum cementing technique for the tibial component in cemented primary total knee replacement (TKR) remains controversial. The technique of cementing, the volume of cement and the penetration are largely dependent on the operator, and hence large variations can occur. Clinical, experimental and computational studies have been performed, with conflicting results. Early implant migration is an indication of loosening. Aseptic loosening is the most common cause of failure in primary TKR and is the product of several factors. Sufficient penetration of cement has been shown to increase implant stability.

This review discusses the relevant literature regarding all aspects of the cementing of the tibial component at primary TKR.

Cite this article: Bone Joint J 2013;95-B:295–300.

The technique of femoral cement-in-cement revision is well established, but there are no previous series reporting its use on the acetabular side at the time of revision total hip replacement. We describe the technique and report the outcome of 60 consecutive acetabular cement-in-cement revisions in 59 patients at a mean follow-up of 8.5 years (5 to 12). All had a radiologically and clinically well-fixed acetabular cement mantle at the time of revision. During the follow-up 29 patients died, but no hips were lost to follow-up. The two most common indications for acetabular revision were recurrent dislocation (46, 77%) and to complement femoral revision (12, 20%).

Of the 60 hips, there were two cases of aseptic loosening of the acetabular component (3.3%) requiring re-revision. No other hip was clinically or radiologically loose (96.7%) at the latest follow-up. One hip was re-revised for infection, four for recurrent dislocation and one for disarticulation of a constrained component. At five years the Kaplan-Meier survival rate was 100% for aseptic loosening and 92.2% (95% CI 84.8 to 99.6), with revision for any cause as the endpoint.

These results support the use of cement-in-cement revision on the acetabular side in appropriate cases. Theoretical advantages include preservation of bone stock, reduced operating time, reduced risk of complications and durable fixation.

Introduction: The medial unicompartmental knee prosthesis (UKA) is less invasive than total knee arthroplasty (TKA) and preserves undamaged structures of the joint. The range of movement and recovery are better in UKA, while postoperative pain reduction is at least equal to TKA. UKA have a higher revision rate than TKA (15% vs 10% after 10 years). One main reason for revision is mechanical loosening¹. There is a paucity of information regarding cement fixation of UKA. We compared jet lavage to conventional lavage with focus on cement pressures, interface temperatures and cement penetration.

Materials and Methods: UKA was performed in 10 paired entire human cadaver legs (Oxford Phase III, Biomet, Dordrecht, NL). Customized tibial implants and a pressure probe insert were used to measure the cement pressure anterior, posterior and near the implant fin during implantation and polymerisation. A drilling and fixation jig was used for standardized positioning of the three temperature probes. The polymerization heat was measured 5 mm below the bone surface at the medial and lateral plateau as well as under the fin. The same cementing technique was performed for all knees using Refobacin^® Bone Cement R. One side of the paired knees was cleaned using jet lavage, contra lateral cleaning was done with conventional lavage. The lavage volume was equal for both

Methods: AP radiographs were taken and digitalized to quantify the cement penetration areas and depths, using a pixel-analysis-software. Group comparisons were done with the Wilcoxon-Test using SPSS (SPSS Inc., Chicago, Illinois).

Results: Average cement pressure under the tibial implant is significantly higher for conventional lavage (avg cement pressure 25.69 ± 17.85 kPa, p= 0.005) than for jet lavage (avg cement pressure 13.28 ± 12.82 kPa). Mean temperature increase measured 5 mm below the bone surface medial and lateral, as well as under the implant fin, were statistically significant higher for the cementing technique with jet lavage (lat. 14.10 ± 5.72°C, p= 0.018/med. 8.49 ± 4.20°C, p= 0.176/fin 5.95 ± 1.92°C, p= 0.063) than for the conventional lavage (lat. 9.42 ± 5.17°C/med. 6.42 ± 2.21°C/fin 3.96 ± 2.03°C). On AP radiographs, cement penetration areas under the tibial implant were significantly higher for jet lavage (penetration area: 122.15 ± 33.94 sq mm, p= 0.046) than for conventional lavage (penetration area: 89.82 ± 23.92 sq mm).

Discussion: The use of jet lavage showed clear advantages in our cadaver studies. Jet lavage resulted in higher cement penetration despite of lower cement pressures under the tibial implant. The higher cement penetration lead to higher interface temperatures but exposure to high temperatures over 50 °C with a risk for bone necrosis could not be measured.

Introduction

Total Hip Arthroplasty (THA) is currently one of the most widely performed surgical procedures in clinical orthopaedic practice. Despite the recorded number of uncemented implants has steadily increased in recent years, cemented fixation still remains the benchmark in THA, accounting for most of the procedures performed nowadays. The Friendly Short is a novel cemented short-stem that grants a less invasive and more bone conservative approach due to its shortened height and innovative cementing technique. It is indicated to treat elderly patients with the aim of preserving bone diaphysis while decreasing postoperative recovery times. Its instrument set allows to optimize the cement mantle thickness via an improved pressurization and stem centralization system.

We report the results of simple laboratory experiments which showed that bleeding pressures known to occur at the bone surface during total hip arthroplasty may compromise the integrity of the bone-cement interface and the cement itself. Such undesirable effects can be prevented by maintaining adequate pressure on the cement until its increased viscosity can resist displacement caused by the bleeding pressure.

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.

Introduction

Aseptic loosening has been reported to be the most common, contemporary mode of total knee arthroplasty failure. It has been suggested that the etiology of revision due to loosening can be attributed, in part, to joint imbalance and the variability inherent in standard surgical techniques. Due to the high prevalence of revision, the purpose of this study was to quantify the change in kinetic loading of the knee joint before versus after the application of the final cement-component complex.

INTRODUCTION

The cement quantity and distribution within femoral hip resurfacings are important for implant survival. Too much cement could cause thermal bone necrosis during polymerisation. Insufficient cement and cement-implant interfacial gaps might favour mechanical loosening. Exposed cancellous bone within the implant, might facilitate debris-induced osteolysis. This study assessed the impact of the cementing technique on the cement mantle quality in hip resurfacing.

Introduction: Stem alignment and cement mantle thickness influence stress distribution on the cement-bone and the bone-cement interfaces. Malposition of the implant and an incomplete cement mantle can lead to suboptimal long-term results. The proximal and distal centralisers that are currently available have shown severe limitations in their clinical application and do not centralise the stem in the lateral plane.

Aim: To evaluate a new stem-positioning system.

Method: One hundred Friendly (Lima LTO) stems implanted between October 1999 and October 2000 have been evaluated radiographically for stem centralisation and cement mantle thickness in both projections. One surgeon used the same technique in all patients and employed a newly designed set of proximal and distal centralisers.

Results: All cases had an acceptable and complete cement mantle. In only seven cases cement thickness was below 2mm in Gruen zone 14. Stem-bone contact was never observed. No patient had migration of the distal plug during pressurisation or complete cement defects. In eight cases mild (2 degrees to 4 degrees) valgus deviation of the stem was found. None of the distal centralisers failed whilst one of the proximal centralisers broke during insertion of the stem without influencing the final result.

Discussion: Cementing the stem is the most delicate phase of cemented total hip replacement. The use of proximal and distal centralisers is mandatory to prevent malposition which in turn results in incomplete cement mantle. The system employed in this series appears accurate and reproducible for stem alignment.

We performed 83 consecutive cemented revision total hip arthroplasties in 77 patients between 1977 and 1983 using improved cementing techniques. One patient (two hips) was lost to follow-up. The remaining 76 patients (81 hips) had an average age at revision of 63.7 years (23 to 89).

At the final follow-up 18 hips (22%) had had a reoperation, two (2.5%) for sepsis, three (4%) for dislocation and 13 (16%) for aseptic loosening. The incidence of rerevision for aseptic femoral loosening was 5.4% and for aseptic acetabular loosening 16%. These results confirm that cemented femoral revision is a durable option in revision hip surgery when improved cementing techniques are used, but that cemented acetabular revision is unsatisfactory.

The ‘cement reaction’ is a recognised cardio-respiratory response to methylmethacrylate bone cement, characterised by hypotension, reduced cardiac output, and on occasion fatal circulatory collapse. It is seen in 0.5-1% of cemented hip arthroplasties during the insertion and pressurisation of cement into the femur, and is believed to be secondary to marrow thromboembolism, the vasodilatory effect of methylmethacrylate, or a combination of the two. A number of steps, within the operating surgeon's control, can be undertaken to reduce the risk of the ‘cement reaction’ occurring.

An e-mail based questionnaire was sent to all trainees and consultants in the West of Scotland containing eight questions relating to cementing technique when performing hemiarthroplasty of the hip. The questions related to measures to reduce the potential for ‘cement reaction’, e.g.: whether or not they routinely use a cement restrictor.

Seventy-two complete replies were received. For five of the eight measures, the surgeons routinely employed the suggested practices. For the remaining three, the consensus opinion was contrary to the suggested practice for reduction of the risk of ‘cement reaction’. These were with respect to the surgical approach employed, whether or not to attempt to remove all cancellous bone from the proximal femur, and the use, or not, of a venting tube during cement insertion. In all three cases, the difference was statistically significant on chi-squared testing.

The cohort of surgeons questioned routinely employ more than half of the methods suggested to reduce the potential for ‘cement reaction’ in hemiarthroplasty of the hip. Further surveys of why they do, or do not, undertake certain practices during cementing would help improve awareness of ‘cement reaction’, and perhaps reduce the incidence of this potentially fatal phenomenon.