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The Evolution of Contemporary Cementation Techniques

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Bone cement was commonly used by dentists in the mid-20th century, but Charnley first proposed using polymethylmethacrylate to anchor the implants of a hip replacement in 1960.¹ Although the working and curing characteristics of bone cement have been refined over the years, its chemical composition has basically remained the same, but cementation technique has changed dramatically (Table).

Early, or “first-generation,” cementing techniques did not involve bone preparation (ie, washing or drying) before insertion of the cement. In addition, the cement was inserted antegrade by hand with little attempt at pressurization beyond finger packing. An intramedullary plug was not used. These techniques caused the potential for cement lamination, inclusion of blood or voids within the cement, inadequate cement mantles, and poor penetration of the cement into the interstices of the cancellous bone. Despite the limitations of early cement techniques, there are many reports of good long-term survivorship of prostheses inserted using these techniques.^2-4

Cement is a grout, not a glue. Pressurization of cement increases its penetration into the interstices of cancellous bone.⁵ This intrusion of cement into bone provides the mechanical interlock that is responsible for the shear strength of the fixation interface. Askew et al⁶ and Krause et al⁷ have shown that increased pressurization of cement increased bone penetration and that pressurized cement was associated with higher tensile and shear strengths at the bone-cement interface than finger-packed cement.

Table

Evolution of Cementing Technique Early Generation Second Generation Contemporary Distal femoral plug No Yes Yes Proximal femoral seal No No Yes Acetabular pressurization No No Yes Hand mixing cement Yes Yes No Vacuum mixing cement No No Yes Brushing No Yes Yes Pulsatile lavage No No Yes

Majkowski et al⁸ and Krause et al⁷ also reported that cleaning the bone surface (ie, removing fat, blood, and other debris) promotes better cement penetration, enhances the mechanical interlock, and thus improves the interface shear strength. More recently, Breusch et al⁹ have shown significantly greater penetration of cement into bone cleaned with pulsed lavage than with syringe lavage.

These findings led to the development of cementing techniques through the 1970s and early 1980s that culminated in “second-generation” techniques. The bone was thoroughly cleaned before cement insertion, an intra-medullary plug was used, and the cement was inserted retrograde to reduce blood lamination and voids. These measures improved the penetration of cement into the cancellous bone and thus enhanced the mechanical interlock and the interface fixation strength. Second-generation cementing techniques resulted in a significant reduction in the incidence of femoral loosening.^10,11

Recognizing the importance of pressurization in achieving good fixation with a strong mechanical interlock, “third-generation” (or contemporary) cementation techniques introduced the concept of maintaining pressurization of the cement before and during insertion of the femoral stem. This was achieved by placing a rubber seal around the nozzle of the cement gun, which effectively sealed the proximal end of the femoral canal. After retrograde insertion of the cement, further cement was delivered through the seal. The medullary canal was thus sealed distally and proximally. As more cement was inserted, the pressure increased and the cement was forced into the interstices of the surrounding bone.

It has also been recommended that bone cement should be vacuum mixed.¹² Vacuum mixing not only removes the noxious fumes of the monomer, but also reduces the porosity of the cement. The extent to which an attempt should be made to remove all voids remains contentious because, although voids may act as crack initiators, they can also behave as crack terminators. In addition, nonporous cement may exhibit somewhat excessive contraction on cooling following exothermic polymerization. This may compromise the micro-interlock and thus fixation.

The importance of a complete cement mantle has been recognized¹⁰ and has led to the development of both distal and proximal centralizers. These centralizers facilitate the ability to reproducibly create an adequate cement mantle by over-broaching the desired cavity and placing the stem in the center of the cavity.¹³ The proximal centralizer may also be used to enhance pressurization during and after insertion of the stem.

In vitro experiments have demonstrated better bone penetration and higher interface shear strengths with low-viscosity cements. However, it may prove difficult to pressurise low-viscosity cement sufficiently to overcome the backbleeding pressure, which may result in cement being displaced by blood. Normal viscosity cement is less likely to be displaced by blood and may therefore provide more reliable and reproducible results.

Contemporary cementation techniques include optimization of cement properties by vacuum mixing, cleaning of the endosteal bone with pulsed lavage, retrograde insertion, and pressurization of the cement to enhance the micro-interlock. The viscosity of cement at insertion should be sufficiently low to allow “flow” into and interdigitation with the cancellous bone, but sufficiently high to allow adequate pressurization. Cleaning, drying, and distal venting can reduce blood contamination and lamination of the cement. Distal (+ proximal) centralizers increase the likelihood of reproducibly achieving a complete cement mantle. Based on a study of these techniques, the Swedish Hip Register reported a 95% survivorship at 10 years.¹⁴

Bone cement provides an ideal method of immediate fixation of the prosthetic components of a total hip replacement. The following articles review further refinements to cementation technique that can improve the reproducibility and durability of fixation.

References

1. Charnley J. Anchorage of the femoral head prosthesis to the shaft of the femur. J Bone Joint Surg Br. 1960; 42:28-30.
2. Callaghan JJ, Albright JC, Goetz DD, Olejniczak JP, Johnston RC. Charnley total hip arthroplasty with cement. Minimum twenty-five-year follow-up. J Bone Joint Surg Am. 2000; 82:487-497.
3. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am. 2002; 84:171-177.
4. Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty in patients under the age of 51 years. Follow-up to 33 years. J Bone Joint Surg Br. 2002; 84:540-543.
5. Halawa M, Lee AJ, Ling RS, Vangala SS. The shear strength of trabecular bone from the femur, and some factors affecting the shear strength of the cement-bone interface. Arch Orthop Trauma Surg. 1978; 92:19-30.
6. Askew MJ, Steege JW, Lewis JL, Ranieri JR, Wixson RL. Effect of cement pressure and bone strength on polymethylmethacrylate fixation. J Orthop Res. 1984; 1:412-420.
7. Krause WR, Krug W, Miller J. Strength of the cement-bone interface. Clin Orthop. 1982; 163:290-299.
8. Majkowski RS, Miles AW, Bannister GC, Perkins J, Taylor GJ. Bone surface preparation in cemented joint replacement. J Bone Joint Surg Br. 1993; 75:459-463.
9. Breusch SJ, Norman TL, Schneider U, Reitzel T, Blaha JD, Lukoschek M. Lavage technique in total hip arthroplasty: jet lavage produces better cement penetration than syringe lavage in the proximal femur. J Arthroplasty. 2000; 15:921-927.
10. Barrack RL, Mulroy RD Jr, Harris WH. Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J Bone Joint Surg Br. 1992; 74:385-389.
11. Mulroy RD Jr, Harris WH. The effect of improved cementing techniques on component loosening in total hip replacement. An 11-year radiographic review. J Bone Joint Surg Br. 1990; 72:757-760.
12. Wixson RL. Vacuum mixing of methylmethacrylate bone cement. Trans Orthop Res Soc. 1985; 10:327.
13. Gozzard C, Gheduzzi S, Miles AW, Learmonth ID. An in-vitro investigation of the CPS-Plus femoral stem: influence of the proximal centraliser on cement pressurisation during stem insertion. Acta Orthop Scand. 2003; 74:154-158.
14. Herberts P, Malchau H. Long-term registration has improved the quality of hip replacement: a review of the Swedish THR Register comparing 160,000 cases. Acta Orthop Scand. 2000; 71:111-121.

Author

From the University of Bristol, Department of Orthopaedic Surgery, Bristol Royal Infirmary, Bristol, United Kingdom.