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Holzer LA, Finsterwald MA, Sobhi S, Jones CW, Yates PJ. Application of bone cement directly to the implant in primary total knee arthroplasty. Short-term radiological and clinical follow-up of two different cementing techniques. Arch Orthop Trauma Surg 2024; 144:333-340. [PMID: 37736767 DOI: 10.1007/s00402-023-05057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/02/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE This study aimed to optimize cement application techniques in fully cemented primary total knee arthroplasty (TKA) by comparing the effects of two different approaches: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term presence of radiolucent lines (RLL) as indicators of potential complications. METHODS In this monocentric study, a total of 379 fully cemented primary TKAs (318 patients) were included. The two study groups were differentiated by the technique of cement application: CoB group (cement applied only on bone surface) and CoBaI group (cement applied on both bone surface and implant surface). The presence of RLL or osteolysis was evaluated using the updated Knee Society Radiographic Evaluation System. RESULTS In the whole study population, RLL were present in 4.7% of cases, with a significantly higher incidence in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up, RLL were observed in 29.8% of TKAs in the CoBaI group, while the incidence was lower in the CoB group (24.0%) (not statistically significant). There were two revisions in each group, none of which were due to aseptic loosening. CONCLUSION The findings of this study suggest that the application of bone cement on bone surface only (CoB) may be more beneficial than applying it on both bone surface and implant surface (CoBaI) in terms of short-term presence of RLL in fully cemented primary TKA. Long-term results, especially with regard to aseptic loosening, will be of interest and may provide valuable guidance for future directions in bone cement applications in TKA.
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Affiliation(s)
- Lukas A Holzer
- Department of Orthopaedics, Fiona Stanley Fremantle Hospitals Group, 11 Robin Warren Dr., Murdoch, WA, 6150, Australia.
- Orthopaedic Research Foundation of Western Australia (ORFWA), Perth, WA, Australia.
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Michael A Finsterwald
- Department of Orthopaedics, Fiona Stanley Fremantle Hospitals Group, 11 Robin Warren Dr., Murdoch, WA, 6150, Australia
- Orthopaedic Research Foundation of Western Australia (ORFWA), Perth, WA, Australia
| | - Salar Sobhi
- Department of Orthopaedics, Fiona Stanley Fremantle Hospitals Group, 11 Robin Warren Dr., Murdoch, WA, 6150, Australia
- Orthopaedic Research Foundation of Western Australia (ORFWA), Perth, WA, Australia
| | - Christopher W Jones
- Department of Orthopaedics, Fiona Stanley Fremantle Hospitals Group, 11 Robin Warren Dr., Murdoch, WA, 6150, Australia
- Orthopaedic Research Foundation of Western Australia (ORFWA), Perth, WA, Australia
- Curtin University, Bentley, WA, Australia
- University of Western Australia, Crawley, WA, Australia
| | - Piers J Yates
- Department of Orthopaedics, Fiona Stanley Fremantle Hospitals Group, 11 Robin Warren Dr., Murdoch, WA, 6150, Australia
- Orthopaedic Research Foundation of Western Australia (ORFWA), Perth, WA, Australia
- University of Western Australia, Crawley, WA, Australia
- Department of Orthopaedics, St. John of God Hospital Murdoch, Murdoch, WA, Australia
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Schmicker TL, Goel A, Davis S, Sina Adil SA, Oliashirazi A, Bullock M. The Effect of Working Time and Application Technique on Cement Penetration into a Tibial Model. Arthroplast Today 2022; 16:197-202. [PMID: 35844266 PMCID: PMC9284312 DOI: 10.1016/j.artd.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background Aseptic loosening of the cemented tibial component is a source of failure in total knee arthroplasty. This study examined common techniques for cement application by quantifying depth and volume of penetration into tibia models. Material and methods Thirty-six composite tibia models were cemented with a tibial component using 3 application techniques (gun, osteotome, and layered) with either early or late cement working time. Computed tomography and 3D-modeling were used to quantify volume and depth of penetration. Statistical analysis was conducted with analysis of variance with Bonferroni correction and Student’s t-test. Results No difference was found in overall volume of penetration between early and late cement application (P = .16). Beneath the baseplate, the layered technique had significantly less penetration and averaged less than 3 mm with early and late cement. The gun technique had the greatest depth of penetration with early cement and averaged greater than 3 mm in all zones regardless of cement working time. The osteotome technique achieved significantly greater depth of penetration around the keel with early and late cement, P < .01. Conclusions Using a cement gun ensures adequate penetration beneath the baseplate regardless of cement working time while the osteotome technique is effective to increase penetration around the implant keel. According to our study, applying cement early in its working time may not increase volume of penetration. This study raises concern regarding adequate cement penetration using the layered technique for cementing the tibial component in total knee arthroplasty, and future research is warranted.
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Kaiser D, Zimmerli N, Hartmann R, Bachmann E, Kühn KD, Meyer DC. Systematic Biomechanical Analysis of Prerequisites for Reliable Intraoperative Bonding of Polymethylmethacrylate Bone Cement in Preexisting Cement in Revision Arthroplasty. Orthopedics 2021; 44:e55-e60. [PMID: 33089336 DOI: 10.3928/01477447-20201007-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/24/2019] [Indexed: 02/03/2023]
Abstract
Removal of a stable cement mantle may be invasive and time consuming and may result in unnecessary damage to bone and surrounding soft tissue. The goal of this study was to investigate the feasibility of the use of polymethylmethacrylate cement on preexisting cement as well as to explore the prerequisites for practical clinical use under standardized laboratory conditions. The strength of the cement-cement interface was evaluated with a 4-point bending to failure test, according to International Organization for Standardization 5833, as well as standardized shear strength, according to American Society for Testing and Materials D732. Various intraoperative cleaning agents were tested to remove simulated contamination with bone marrow. Contamination of the cement-cement interface with bone marrow decreases bending strength, modulus, and shear strength. Removal of the bone marrow with a degreasing agent significantly increases bending strength as well as bending modulus and can increase shear strength up to 9% compared with use of a nondegreasing agent. The cement-cement interface may reach up to 85% of bending strength, 92% of bending modulus, and comparable shear strength compared with a uniform cement block. Meticulous removal of fatty contaminant is important. Use of a degreasing agent further increases the stability of the cement-cement interface. With these precautions, it is safe to assume that the combined molecular and mechanical interlock is sufficient for most clinical applications and will not represent the weakest link in prosthetic revision. [Orthopedics. 2021;44(1):e55-e60.].
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Refsum AM, Nguyen UV, Gjertsen JE, Espehaug B, Fenstad AM, Lein RK, Ellison P, Høl PJ, Furnes O. Cementing technique for primary knee arthroplasty: a scoping review. Acta Orthop 2019; 90:582-589. [PMID: 31452416 PMCID: PMC6844414 DOI: 10.1080/17453674.2019.1657333] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The optimal cementing technique for primary total knee arthroplasty (TKA) remains unclear. We therefore performed a scoping review based on available studies regarding cementation technique in primary TKA and unicondylar knee arthroplasty (UKA).Patients and methods - A search in 3 databases identified 1,554 studies. The inclusion criteria were literature that studied cementing technique in primary TKA or UKA. This included cement application methods, full or surface cementing, applying cement to the bone and/or prosthesis, stabilization of the implant during curing phase, bone irrigation technique, drilling holes in the bone, use of suction, and the timing of cementation. 57 studies met the inclusion criteria.Results - The evidence was unanimously in favor of pulsatile lavage irrigation, drying the bone, and drilling holes into the tibia during a TKA. All studies concerning suction recommended it during TKA cementation. 7 out of 11 studies favored the use of a cement gun and no studies showed that finger packing was statistically significantly better than using a cement gun. There is evidence that full cementation should be used if metal-backed tibial components are used. Applying the cement to both implant and bone seems to give better cement penetration.Interpretation - There are still many knowledge gaps regarding cementing technique in primary TKA. There seems to be sufficient evidence to recommend pulsatile lavage irrigation of the bone, drilling multiple holes, and drying the bone before cementing and implant insertion, and applying cement to both implant and on the bone.
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Affiliation(s)
- Anders M Refsum
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen;
| | - Uy V Nguyen
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen;
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen; ,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Birgitte Espehaug
- Centre for Evidence-Based Practice, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen;
| | - Anne M Fenstad
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Regina K Lein
- Medical Library, University of Bergen, Bergen, Norway
| | - Peter Ellison
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Paul J Høl
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen; ,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Ove Furnes
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen; ,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; ,Correspondence:
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Stefanovich-Lawbuary NS, Parry MC, Whitehouse MR, Blom AW. Cement in cement revision of the femoral component using a collarless triple taper: a midterm clinical and radiographic assessment. J Arthroplasty 2014; 29:2002-6. [PMID: 24927866 DOI: 10.1016/j.arth.2014.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 04/27/2014] [Accepted: 05/05/2014] [Indexed: 02/01/2023] Open
Abstract
This study describes the midterm clinical and radiological results of the cement in cement technique for the femur using a collarless triple taper. Radiographic assessment was made retrospectively from 44 patients at two time points. Clinical outcomes included the Oxford Hip Score, EQ5D and Self Reported Patient Satisfaction Scale. Implant and patient survival were also recorded. The mean clinical follow up period was 5years 3months and the radiological follow up 2years 10months. The mean OHS was 34, the mean EQ5D 0.814 and the mean SAPS 94. Kaplan-Meier survival with revision, as the end point was 95.2% at 11years with a survivorship of 76.5% with death as the end point. Cement in cement revision using a collarless triple tapered stem demonstrates promising results both clinically and radiologically at midterm follow up.
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Affiliation(s)
- Natalija S Stefanovich-Lawbuary
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Westbury on Trym, Bristol, UK, BS10 5NB
| | - Michael C Parry
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Westbury on Trym, Bristol, UK, BS10 5NB
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Westbury on Trym, Bristol, UK, BS10 5NB
| | - Ashley W Blom
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Westbury on Trym, Bristol, UK, BS10 5NB
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Schlegel UJ, Bishop NE, Püschel K, Morlock MM, Nagel K. Comparison of different cement application techniques for tibial component fixation in TKA. INTERNATIONAL ORTHOPAEDICS 2014; 39:47-54. [DOI: 10.1007/s00264-014-2468-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 07/13/2014] [Indexed: 10/25/2022]
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Rudol G, Wilcox R, Jin Z, Tsiridis E. The effect of surface finish and interstitial fluid on the cement-in-cement interface in revision surgery of the hip. ACTA ACUST UNITED AC 2011; 93:188-93. [DOI: 10.1302/0301-620x.93b2.24759] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The mechanical performance of the cement-in-cement interface in revision surgery has not been fully investigated. The quantitative effect posed by interstitial fluids and roughening of the primary mantle remains unclear. We have analysed the strength of the bilaminar cement-bone interface after exposure of the surface of the primary mantle to roughening and fluid interference. The end surfaces of cylindrical blocks of cement were machined smooth (Ra = 200 nm) or rough (Ra = 5 μm) and exposed to either different volumes of water and carboxymethylcellulose (a bone-marrow equivalent) or left dry. Secondary blocks were cast against the modelled surface. Monoblocks of cement were used as a control group. The porosity of the samples was investigated using micro-CT. Samples were exposed to a single shearing force to failure. The mean failure load of the monoblock control was 5.63 kN (95% confidence interval (CI) 5.17 to 6.08) with an estimated shear strength of 36 MPa. When small volumes of any fluid or large volumes were used, the respective values fell between 4.66 kN and 4.84 kN with no significant difference irrespective of roughening (p > 0.05). Large volumes of carboxymethylcellulose significantly weakened the interface. Roughening in this group significantly increased the strength with failure loads of 2.80 kN (95% CI 2.37 to 3.21) compared with 0.86 kN (95% CI 0.43 to 1.27) in the smooth variant. Roughening of the primary mantle may not therefore be as crucial as has been previously thought in clinically relevant circumstances.
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Affiliation(s)
- G. Rudol
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon A, Great George Street, Leeds LS1 3EX, UK
| | - R. Wilcox
- Institute of Medical and Biological Engineering, School of Mechanical Engineering University of Leeds, Leeds LS2 9JT, UK
| | - Z. Jin
- Institute of Medical and Biological Engineering, School of Mechanical Engineering University of Leeds, Leeds LS2 9JT, UK
| | - E. Tsiridis
- University of Thessaloniki, University Campus GR 54124, Thessaloniki, Greece
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Mandziak DG, Howie DW, Neale SD, McGee MA. Cement-within-cement stem exchange using the collarless polished double-taper stem. J Arthroplasty 2007; 22:1000-6. [PMID: 17920472 DOI: 10.1016/j.arth.2007.06.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 06/01/2007] [Indexed: 02/01/2023] Open
Abstract
The clinical and radiographic outcomes of the cement-within-cement femoral stem exchange technique at revision hip arthroplasty were determined. Twenty-three revisions with a collarless polished double-taper stem design were prospectively monitored at up to 12 years. The most common indications for revision were recurrent dislocation and acetabular revision. Radiographic stem subsidence was measured by the Ein Bild Röentgen Analyse method. There was no stem re-revision and no radiographic loosening. Stem within cement subsidence, an intentional design feature of this stem, averaged 0.8 mm (range, 0-2 mm). The average subsidence was similar to that in primary hip arthroplasty. The excellent long-term results of cemented collarless polished taper stems for primary and revision hip arthroplasty can be extended even further by cement-within-cement exchange, which preserves the femur.
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Affiliation(s)
- Daniel G Mandziak
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Weinrauch PC, Bell C, Wilson L, Goss B, Lutton C, Crawford RW. Shear properties of bilaminar polymethylmethacrylate cement mantles in revision hip joint arthroplasty. J Arthroplasty 2007; 22:394-403. [PMID: 17400096 DOI: 10.1016/j.arth.2006.04.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2005] [Accepted: 04/13/2006] [Indexed: 02/01/2023] Open
Abstract
Although cement-within-cement revision arthroplasty minimizes the complications associated with removal of secure PMMA, failure at the interfacial region between new and old cement mantles remains a theoretical concern. This article assesses the variability in shear properties of bilaminar cement mantles related to duration of postcure and the use of antibiotic cements. Bilaminar cement mantles were 15% to 20% weaker than uniform mantles (P < .001) and demonstrated variability in shear strength related to duration of postcure of the freshly applied cement (P < .001). The use of Antibiotic Simplex did not significantly influence interfacial cement adhesion (P = .52). Interfacial adhesion by mechanisms other than mechanical interlock plays a significant role in the bond formed between new and old PMMA cements, with an important contribution by diffusion-based molecular interdigitation. In the presence of a secure cement-bone interface, we recommend cement-within-cement revision techniques in suitable patients.
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Affiliation(s)
- Patrick C Weinrauch
- School of Engineering Systems, Queensland University of Technology, Brisbane, Australia
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