Adhesive bonding of medical and implantable devices

Although there are many commercially available medical-grade adhesives, their use for new applications requires detailed investigation. It is also important that as well as the initial joint strength, durability of the bonded components during intended use, including exposure to low and high temperatures, stress, fluids and sterilisation, are investigated. Design of accelerated ageing tests, which can simulate the service environments, is critical in providing realistic durability data. Interpretation of ageing data and lifetime prediction of the joint is essential in assessing the performance of medical devices. Emergence of new types of adhesives as well as further development of precision dispensing and rapid-curing technologies offer many exciting and commercially attractive opportunities for joining medical devices.

Comparison between two clinical procedures for bonding fiber posts into a root canal: a microscopic investigation

The purpose of this study was to evaluate the influence of two brushes used as carriers of a primer-adhesive solution as to the formation of resin tags, adhesive lateral branches, and a hybrid layer when used to bond translucent fiber posts. Twenty endodontically treated teeth, extracted for periodontal reasons, were used. The samples were randomly divided into two groups of 10 samples each (Group 1: Microbrush + Scotchbond 1 + Rely X ARC resin cement; Group 2: small plastic brush + Scotchbond 1 + Rely X ARC resin cement). The adhesive system and resin cement were used strictly following manufacturers' instructions. The priming-adhesive solution of the one-bottle system was light-cured before placing the resin cement and the post. Twenty translucent fiber posts were used. After luting procedures, root samples were processed for SEM observations. The adhesive system showed a resin dentin interdiffusion zone (RDIZ), resin tag, and adhesive lateral branch formation. Microscopic examination of restored interfaces of group 1 showed a higher percentage (p < 0.05) of RDIZ than those found in samples of group 2. In group 1 samples, RDIZ morphology was well detectable and uniform in all thirds of the root canals. In group 2, RDIZ was not visible in the apical third. No statistically significant differences were found among the two groups coronally and at the middle third, but the apical third of group 1 showed significantly more resin tag formation than group 2. The characteristic reverse cone shape of resin tags was always noted in the coronal and middle third of the root canals of both groups and in the apical third of group 1. In the apical third of group 2 root canals, the resin tags showed a less uniform morphology and a shorter length than those found in the other observed thirds.

Cementless total hip arthroplasty with a tapered, rectangular titanium stem and a threaded cup: a minimum ten-year follow-up

BACKGROUND

We report the results of cementless total hip arthroplasty with a tapered, rectangular titanium stem that was introduced in 1979 and continues to be used today with only minor changes. The aim of the design is to achieve primary stability to resist rotational and axial forces through precision rasping and press-fit implantation of a tapered, rectangular femoral component.

METHODS

Between October 1986 and November 1987, 208 total hip arthroplasties with insertion of a tapered, rectangular titanium stem and a threaded cup without cement were performed in 200 consecutive patients (average age, sixty-one years; range, twenty-two to eighty-four years).

RESULTS

At the time of the latest follow-up, fifty-one patients (fifty-two hips) had died and sixteen patients had been lost to follow-up, leaving 133 patients. Twelve hips had been revised, two in patients who subsequently died, leaving 123 living patients without revision. The median follow-up time was 120.7 months. Five cups needed revision surgery because of aseptic loosening; two, because of massive polyethylene wear; one, because of posttraumatic migration; and one, because of breakage. Three femoral stems were revised: one because of malpositioning (the reoperation was done five days after implantation); one, because of infection; and the third, after multiple failed acetabular revisions. The mean Harris hip score for the patients who did not have revision was 85.4 points (range, 46 to 100 points) at the time of the latest follow-up. Four patients (3%) complained of thigh pain that was not associated with another disorder. According to the criteria of Engh et al., all femoral implants were graded as stable bone-ingrown. The probability of survival of both the femoral and the acetabular component at ten years, with any revision as the end point, was 0.92 (95% confidence interval, 0.88 to 0.97). The probability of survival of the cup was 0.93 (95% confidence interval, 0.89 to 0.97), and that of the stem was 0.99 (95% confidence interval, 0.97 to 1.00).

CONCLUSIONS

The results of arthroplasty with a tapered, rectangular titanium stem combined with a conical threaded cup inserted without cement were excellent at a minimum of ten years. Our data suggest that femoral stem fixation continues to be secure, while the threaded cup is prone to aseptic loosening.

The effects of acetabular cup temperature and duration of cement pressurization on cement porosity in a canine total hip replacement model

OBJECTIVE

To determine the effect of acetabular cup temperature and duration of cement pressurization on porosity of the acetabular cement mantel.

STUDY DESIGN

In vitro study.

METHODS

Twenty-four polyurethane foam blocks prepared for acetabular prosthetic implantation were implanted with polyethylene acetabular cups using four combinations and variations of temperature and pressure: (1) high temperature/short-term pressurization; (2) high temperature/long-term pressurization; (3) low temperature/long-term pressurization; and (4) low temperature short-term pressurization. Five 1-mm-thick slices were taken from the center of each block using a tissue processing system. The slices were scanned into a personal computer using a photo slide scanner. Imaging software was used to determine cement surface area and size, number, and distribution of pores. The quality of the cement-implant interface was subjectively evaluated. Statistical analysis of relative cement porosity was performed by a Kruskal-Wallis analysis of variance comparing the four groups individually and combining the short-term pressurization groups versus the long-term pressurization groups.

RESULTS

There were no significant differences in cement porosity between the four test groups (P =.11). There were no significant differences in porosity between the combined groups (P =.48).

CONCLUSIONS

There is no benefit in prewarming acetabular cups before implantation. There are no deleterious effects of short-term pressurization of the cement during implantation.

A technique for the removal of restoration overhangs and finishing and polishing of restoration and preparation margins

Restorations with marginal overhangs are frequently associated with localized periodontal defects. Access to overcontoured approximal margins of restorations can be difficult to obtain, however. A system featuring a multidirectional handpiece is an effective and efficient means of contouring, finishing, and polishing restoration surfaces and margins. In particular, the system facilitates access to approximal and subgingival areas for the removal of marginal excess and overhangs. This system may be a valuable addition to the practitioner's armamentarium for operative procedures.

Efficacy of a self-curing adhesive-resin cement system on luting glass-fiber posts into root canals: an SEM investigation

PURPOSE

The aim of this study was to evaluate the efficacy of a new bonding-luting system in resin tag, adhesive lateral branch, and hybrid layer formation when used in combination with an experimental fiber post.

MATERIALS AND METHODS

Thirty anterior teeth extracted for periodontal reasons were selected for this study. They were endodontically treated and randomly divided into three groups of 10 samples each: group 1 = Excite light-cured bonding agent in combination with Variolink II resin cement; group 2 = Excite dual-cured bonding agent self-activated by an experimental microbrush in combination with MultiLink resin cement; and group 3 = one-step bonding system in combination with Dual Link resin cement. In groups 1 and 3, the primer-adhesive solution was light cured before placing the resin cement and the post, whereas in group 2 the adhesive/luting materials were not light cured. Twenty FRC Postec translucent posts (groups 1 and 2) and 10 EndoAesthetic translucent fiber posts (group 3) were used. One week later, the root samples were processed for scanning electron microscopic (SEM) observations.

RESULTS

Microscopic examinations of restored interfaces from group 2 revealed a resin-dentin interdiffusion zone higher than that seen in samples from groups 1 and 3 (P < .05). At the apical and middle thirds, the samples from group 2 showed significantly more resin tags than the other two groups.

CONCLUSION

The dual-cure self-activating system showed a more uniform resin tag and resin-dentin interdiffusion zone formation along root canal walls than light-curing systems.

Retention of cast posts cemented with zinc phosphate cement using different cementing techniques

PURPOSE

This study compares the effect of different cementation techniques on the retention of cast posts and cores.

MATERIALS AND METHODS

Twenty-four extracted single rooted human teeth were used in this study. After routine preparation of the root canals, the canal space was enlarged with reamers. Direct post patterns were made with acrylic resin. Castings were fabricated using Ni-Cr-Mb alloy. Zinc phosphate cement was used as a luting agent using 4 different methods of cement introduction to the root canal space. This created 4 treatment groups consisting of 6 teeth in each group. In Group A, the cement was applied over the posts only. For the specimens in Group B, the cement was introduced into the root canals with a spiral filler and applied over the posts. In Group C, cement was injected into the root canals and then applied over the posts. Finally, for the specimens in Group D, cement was injected into the root canals and a spiral was used to spread it into the root canals, and cement was also applied over the posts. After cementation, teeth were stored in saline solution. The tensile retentive force of cast posts was evaluated using the Instron testing machine (Instron, Canton, MA).

RESULTS

The retention obtained by the 4 techniques differed significantly (p <.05). The highest tensile force to post dislodgment was observed in Group D, and the least was in Group A. Analysis of variance test revealed a highly significant difference between groups (p <.0001). According to the Fisher exact test, there was a significant increase in retention from Group A to Group D (p <.05).

CONCLUSIONS

Under the conditions of this study, the injection of cement into a root canal space followed by the use of a spiral resulted in the highest level of post retention. Retention was reduced when cement was placed using a Lentulo spiral alone (Kerr/Sybron Corp, Romulus, MI), a Jiffy tube (Teledyne Water Pik, Allegheny Teledyne Co, Fort Collins, CO) alone, or by application to the post only. J Prosthodont 2001;10:37-41.

The effect of cement restrictors on the occlusion of the humeral canal: an in vitro comparative study of 2 devices

An in vitro study investigated the efficacy of cement restrictor devices on cement containment and penetration within the humerus. Eight pairs of preserved humeri were prepared using advanced cementing technique followed by insertion of 1 of 2 cement restrictors. Low-viscosity cement was injected followed by sham humeral stem insertion. Each specimen was sectioned into transverse 10-mm slices. Slices were photographed and digitized to quantify the cement/stem and canal cross-sectional area. Cement penetration was determined from the ratio of cement area to canal area. A significant increase in cement penetration was observed among slices from distal to proximal for both restrictors (P = .02). There was no significant difference in cement penetration, leakage, or migration between restrictors. Five of the 8 specimens migrated, with means of 21.5 +/- 25.0 mm and 24.0 +/- 36.0 mm for the polyethylene and silicone restrictors. Leakage or migration resulted in a significant decrease in cement penetration with the polyethylene restrictors (P = .001). In the silicone restrictor group, migration resulted in decreased cement penetration (P = .04). When using advanced cementing techniques, intramedullary restrictors allow improved cement penetration; however, they do not ensure cement containment.

In vivo measurement of acetabular cement pressurization using a simple new design of cement pressurizer

Aseptic loosening of the acetabular component remains a limiting factor in the long-term success of total hip replacement. An instrumented pressurizer has been designed to allow the intraoperative measurement of acetabular cement pressurization, which is known to contribute to implant fixation. Average intraoperative cement pressures in 16 operations performed by 2 surgeons were 49 +/- 17 kPa (6.4 +/- 2.3 psi) and 47 +/- 17 kPa (6.2 +/- 2.2 psi), and peak pressures were 76 +/- 5 kPa (10.0 +/- 0.6 psi) and 93 +/- 15.kPa (12.2 +/- 1.9 psi), comparable to previous work in vitro. The pressurization required for optimal cement penetration into cleaned low-density cancellous bone is reported to be of the order of 35 to 50 kPa (4.6-6.6 psi) for 30 to 60 seconds, and the present data show that this is attainable in vivo using a simple device.

Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. A prospective, randomized clinical trial

BACKGROUND

Acute hypotension, hypoxemia, cardiac arrest, and sudden death are well recognized complications during total hip arthroplasty, and they have been attributed to embolization of fat and bone marrow. An increase in intramedullary pressure in the femur is the most important pathogenic factor for the development of embolic events. Intravasation of fat, bone marrow, and bone debris during the implantation of a femoral component, and the embolization of these elements through the venous system located along the linea aspera and through the metaphyseal vessels, have been demonstrated experimentally and clinically. The purpose of the present study was to compare the effects of fixation of the femoral component without cement with those of fixation with a bone-vacuum cementing technique on the severity of embolic phenomena and cardiopulmonary impairment during total hip arthroplasty. Fixation with a conventional cementing technique was also evaluated as a control.

METHODS

Sixty patients (sixty hips) were entered into a prospective, randomized clinical trial. The patients were assigned to one of three groups. Group 1 consisted of twenty patients who had the femoral component inserted without cement, Group 2 comprised twenty patients who had the component inserted with a conventional cementing technique, and Group 3 included twenty patients who had fixation with the so-called bone-vacuum cementing technique. In the hips in Group 3, a suction of -800 millibars (-80,000 pascals) was applied to a proximal drainage cannula placed along the linea aspera and a distal drainage cannula placed in the diaphysis in order to produce a vacuum in the medullary cavity of the femur during the application of cement and the insertion of the stem. Transesophageal echocardiography and hemodynamic and blood-gas analysis were performed during the operation.

RESULTS

Severe embolic events (defined as a cascade of fine echogenic particles of less than five millimeters in diameter) were observed in seventeen (85 percent) of the twenty patients during insertion of the stem with use of a conventional cementing technique but in none of the patients who had the stem inserted without cement (p < 0.05). Insertion of the femoral component with the bone-vacuum cementing technique prevented embolic phenomena in all but one patient (5 percent). Arterial oxygen saturation decreased significantly (p < 0.05) from a mean of 99.5 to 92.9 percent after insertion of the stem with a conventional cementing technique, but only slight changes were observed in the patients who had fixation of the component without cement and in those who were managed with the bone-vacuum cementing technique. Intraoperative pulmonary shunt values increased a mean of 24 percent (p < 0.05) when the femoral component was inserted with a conventional cementing technique, but with the numbers available we did not detect a significant change in those values when the component was fixed without cement or when it was inserted with use of the bone-vacuum cementing technique.

CONCLUSIONS

The present study showed that severe embolic events and intraoperative pulmonary impairment are common when a femoral component is fixed with use of a conventional cementing technique. The results clearly demonstrated a low risk of embolism during total hip arthroplasty when the femoral component was fixed without cement and when it was fixed with the bone-vacuum cementing technique. The ability of a patient to withstand an embolic event should be considered before fixation of the femoral component with use of a conventional cementing technique is planned.

Advances in the use of glass-ionomeric cement. Part 1: Experimental results and portrayal of a technique

The objective of this study was to develop a method of cement microapplication using glass-ionomeric cement. The results of an experimental study to design a microapplication method of glass-ionomeric cement (Ionocem) are presented. Typical middle ear implant materials, as well as human temporal bones and middle ear ossicles, were used to test the efficiency of this application method. Two different versions of Ionocem, low and normal viscosity, were tested under different temperatures and with several application tools. Sufficient processing time could be achieved by cooling the cement down to 4 degrees C. A subcutaneous insulin syringe with a milled-off tip proved to be cost-effective, efficient and versatile. Using this instrument, durable and secure cementation between the parts tested could be achieved. This method may be of significant importance in otologic research and microsurgical routine. In part 2, experimental animal results will follow, as the method portrayed was used to secure parts of a totally implantable middle ear hearing device.

An in vitro study of a new design of acetabular cement pressurizer

Aseptic loosening of the acetabular component remains one of the limiting factors in the long-term success of total hip arthroplasty. Cement pressurization has been shown to improve fixation. A new pressurizer has been designed that seals around the rim of the acetabulum and covers the transverse ligament notch with a flap. The results of in vitro testing of this device are presented and compared with those of pressure generated by insertion of an acetabular cup. The pressurizer allowed sustained, uniform cement pressurization. Peak pressures with the new pressurizer were 180 kPa at both the iliac region of the rim and the pole of an instrumented model acetabulum, compared with 55 kPa at the rim and 120 kPa at the pole on cup insertion. Pressures were maintained in the range of 80-90 kPa. The flap was effective in preventing cement leakage from the notch, and pressures were higher than when the flap was absent. Cup insertion alone gave only transient pressurization, substantially less near the rim of the acetabulum than at the pole. Peripheral pressurization may be significant in producing secure local fixation at the rim of the acetabulum, in particular in the region of the ilium (Charnley zone 1), where radiolucencies are most commonly observed and where stresses in the implanted acetabulum are highest. Improved rim fixation may also play a role in preventing the ingress of wear debris.

The cement mantle in femoral impaction allografting. A comparison of three systems from four centres

An analysis of the cement mantle obtained with the Exeter impaction allografting system at one centre showed that it was either deficient or absent in almost 47% of Gruen zones. We therefore examined the mantle obtained using this system at another hospital and compared the results with those from the CPT and Harris Precoat Systems at other centres. The surgical indications for the procedure and the patient details were broadly similar in all four hospitals. There was some variation in the frequency of use of cortical strut allografts, cerclage wires and wire mesh to supplement the impaction allograft. Analysis of the cement mantles showed that when uncertain Gruen zones were excluded, the incidence of zones with areas of absence or deficiency of the cement was 47% and 50%, respectively, for the two centres using the Exeter system, 21% for the CPT system and 18% for the Harris Precoat system. We measured the difference in size between the proximal allograft impactors and the definitive prosthesis for each system. The Exeter system impactors are shorter than the definitive prosthesis and taper sharply so that the cavity created is inadequate, especially distally. The CPT proximal impactors are considerably longer than the definitive prosthesis and are designed to give a mantle of approximately 2 mm medially and laterally and 1.5 mm anteriorly and posteriorly. The Harris Precoat proximal impactors allow for a mantle with a circumference of 0.75 mm in the smaller sizes and 1 mm in the larger. Many reports link the longevity of a cemented implant to the adequacy of the cement mantle. For this reason, femoral impaction systems require careful design to achieve a cement mantle which is uninterrupted in its length and adequate in its thickness. Our results suggest that some current systems require modification.

Influence of temperature and vacuum mixing on bone cement properties

To analyze the influence of varying viscosity and mixing temperature (22 degrees C and 6 degrees C) on macro- and microporosity, density, and compressive strength in vacuum mixed bone cement, high, medium, and low viscosity cement were mixed in 2 vacuum mixing systems and compared with bowl mixing at atmospheric pressure. At 22 degrees C, vacuum mixing significantly reduced void volume to less than approximately 3 per mill. The reduction was most pronounced in low viscosity cement. Microporosity also was reduced in all cements by vacuum mixing and to highest degree in low viscosity cement. At 6 degrees C the reduction of micropores was more pronounced in high viscosity cement. In medium and especially low viscosity cement, the prechilling gave an increased number of micropores. Cement density also was significantly reduced in low viscosity cement at 6 degrees C. Vacuum mixing significantly increased compressive strength by approximately 15% in all cement types (30 days). The temperature did not significantly influence compressive strength, but low viscosity cement generally was stronger when mixed at 22 degrees C. It is concluded that vacuum mixing improves cement quality. However, the temperature influences the final result; in particular, low viscosity cement should not be mixed after prechilling to 6 degrees C.

In vitro and in vivo studies of pressurization of femoral cement in total hip arthroplasty

Improvements in cementing techniques in the absence of pressurization of the cement have led to major increases in the long-term success rate of fixation of the femoral components of cemented total hip arthroplasty (THA). The strength of the cement-bone interface is strongly related to cement intrusion into the bone. The depth of cement intrusion, in turn, is correlated with the cement-intrusion pressure. Thus, adding cement pressurization to those current techniques that have already been validated may further increase the long-term durability of fixation of the femoral component of cemented THA. To assess cement pressurization in the proximal femur for THA, the authors compared in vitro the efficacy of three existing pressurization systems (the Johnson and Johnson system [New Brunswick, NJ], the Miller system [Zimmer, Warsaw, IN], and the Zimmer system [Zimmer]) in cadaver femurs using pressure transducers and evaluated their ease and optimization for clinical use. The authors then selected one (the Zimmer system) for use in studies in vivo to quantify the actual pressures achieved in the medullary canal in vivo under surgical conditions using pressure transducers placed throughout the femoral cortex. Each of the three commercially available femoral cement pressurization systems has its own advantages and disadvantages. All three systems were shown to produce average peak cement-intrusion pressures in vitro of over 21 N/cm2 (30 psi) throughout the cement mantle including, importantly, in the proximal portion of the femur.(ABSTRACT TRUNCATED AT 250 WORDS)

A new femoral cement restrictor

The authors report on the clinical trial of a new femoral cement restrictor for use during hip arthroplasty. Instrumentation and technique are described. The restrictor has three components made of high-density polyethylene that fit one inside the other and is available in small, medium, and large sizes. The advantages of this new restrictor are ease of use and secure fixation in the femoral canal when deployed. Because of its inherent strength and design, small particles do not break off during insertion. The apex of the restrictor points proximally and is cupped. This helps in centralizing the stem. It also assists in obtaining good cement pressurization as it does not distally migrate in the femoral canal when pressurization is attempted. Also, no cement escapes distally beyond it. Furthermore, should revision surgery be required, the restrictor can be easily removed without the need for windowing the femoral cortex.