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Bone cement use decreasing in hand, wrist applications, rising in unique cases
Surgeons agree that cement is good for temporary fixation, bone void filling after tumors.
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Hand surgeons have generally discontinued use of bone cement in total wrist and small joint arthroplasty, but they do not rule out the use of bone cement altogether.
“The use of cement in the hand and wrist has generally been unsatisfactory and relevantly disastrous, mainly because of the size of the bones and the difficulty with revisions if cemented prostheses haven’t worked,” Barry P. Simmons, MD, told Orthopedics Today.
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However, most surgeons still reserve a place for bone cement in unique cases. Amy L. Ladd, MD, an Orthopedics Today editorial board member, uses polymethylmethacrylate (PMMA) cement in total wrist arthroplasty when deemed necessary to supplement fixation in patients with osteopenic or bony abnormalities. She also uses calcium phosphate bioabsorbable bone cement to fill metaphyseal fracture voids.
She and others, including Simmons, still believe bone cement can be used after tumor resection and for temporary fixation.
“Except for some especially remarkable situations, such as a [temporary] bone filler for bone loss in a badly injured extremity … or for fixation in pathological fractures around the wrist and hand, I don’t think there’s an indication for cement,” said Simmons, section editor for hand and upper extremity on Orthopedics Today’s editorial board.
Off-label use of prostheses
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The FDA requires bone cement use with some wrist and digital prostheses, but surgeons find that it does not offer extra advantages and in some cases, has failed at the bone-cement interface, Simmons said.
“It’s my understanding that all of the total wrist replacement prostheses currently in use are cleared by the FDA under the same product code that reads ‘Wrist joint, metal/polymer, semi-constrained, cemented prosthesis.’ While most of these prostheses are currently implanted without the use of bone cement, the manufacturers of those devices recognize that their use without bone cement is an off-label application,” Jim Strickland, MD, told Orthopedics Today.
With improved implant designs and osseointegrated stems, surgeons can achieve bone ingrowth and stability that couldn’t be achieved in the past, minimizing the need for bone cement, said Strickland, an Orthopedics Today editorial board member.
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Image: Ladd A |
In unique circumstances, however, surgeons might improve the implants’ ability by filling the medullary canal with bone cement before inserting the implant stems, Strickland said.
“Those indications may be very poor bone stock, severe osteoporosis, previous erosive processes, or other circumstances where the surgeon feels that the stability and long-term performance of the components … may be improved by the use of supplementary bone cement,” Strickland said.
Current indications cement
Although most hand and upper limb surgeons feel that the practice of using PMMA has fallen out of favor, Ladd notes that Sir John Charnley reported on the utility of PMMA for the treatment of osteoporotic distal radius fractures, an augmentation technique in use today especially in hip fractures and vertebroplasty. Its use in the upper limb for this indication, however, is rare.
Ladd uses calcium phosphate bone cement to fill metaphyseal voids in distal radius fractures as an adjunct in structural support.
“In conjunction with … plates, screws [or] external fixation devices, [biologically active cement] is … a reasonable complement to form a hybrid construct for fractures, particularly distal radius fractures with large metaphyseal voids,” Ladd told Orthopedics Today.
Some hand surgeons also temporarily insert antibiotic-loaded cement in traumatic fractures.
“Sometimes we’ll use bone cement impregnated with antibiotics to fill a void and try to sterilize the soft tissue envelope, and then go back and fill that area with the bone graft,” Michael Pannunzio, MD, told Orthopedics Today.
Pannunzio also routinely uses bone cement after tumor resections to fill defects or cavities left behind in the bone.
“The heat generated by the bone cement tends to give you a little bit of additional tumor-kill,” Pannunzio said. “[Bone cement also] helps you to see if there is a recurrence of the tumor because it is easy to differentiate between the tumor and the bone cement.”
For more information:
- Amy L. Ladd, MD, Robert A. Chase Hand & Upper Limb Center, 900 Welch Road, Suite 15, Palo Alto, CA 94304; 650-723-6796; aladd@stanford.edu.
- Michael Pannunzio, MD, Reconstructive Hand Surgeons of Indiana, 13421 Old Meridian Street, Suite 200, Carmel, IN 46032; 317-249-2616; mpannunzio@indianahandsurgeons.com.
- Barry P. Simmons, MD, Brigham & Women’s Hospital, 75 Francis Street, Boston, MA 02115; 617-732-5378; bsimmons@partners.org.
- Jim Strickland, MD, Reconstructive Hand Surgeons of Indiana, 13421 Old Meridian Street, Suite 200, Carmel, IN 46032; 317-249-2616; jim@docstrickland.com. He is a codeveloper of the Maestro total wrist replacement system in conjunction with Biomet, for which he serves as a consultant. He receives no royalties from the implant.