The mechanical effect of the existing cement mantle on the in-cement femoral revision

Cement-within-cement technique in revision reverse shoulder arthroplasty: A systematic review of biomechanical data, and clinical outcomes

Background

The purpose of this research was to systematically review and summarize the existent literature on the use of the cement-within-cement technique for revision reverse shoulder arthroplasty (RSA).

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed/Medline, Scopus, and EMBASE databases were searched for relevant studies. We included clinical studies in which patients underwent RSA revision using the cement-within-cement method for the humeral component, and studies that evaluated the biomechanical performance or described the surgical technique. The methodological risk of bias was assessed using the methodological index for non-randomized studies scale.

Results

The search yielded 516 records, of which two clinical and one biomechanical study met the inclusion criteria, involving 133 patients and 20 synthetic humeri. The intraoperative complication rate was 18%, all of which involved humeral fractures. The postoperative complication rate was 18% among 35 patients. The combined re-revision rate was 9%, with a reported humeral component survival rate of 100% at 2 years and 96% at 5 years. Periprosthetic fractures (1.5%) and humeral stem loosening (1.5%) led to re-revision surgeries in all cases. All studies reported improved patient-reported outcomes and range of motion. The biomechanical study demonstrated increased rotational stability in models that used larger humeral stems.

Conclusions

The cement-within-cement method is a viable option for revision RSA, showing positive outcomes in terms of stability, range of motion, and clinical functional scores. The complication rate is similar to that of other revision strategies; however, the prevalence of intraoperative humeral fractures may be higher. Nevertheless, future studies with larger sample sizes and longer follow-up periods are needed to refine patient selection, determine the efficacy of long-term use, and identify factors that may influence outcomes after the cement-within-cement revision technique. Further research on an optimized stem fixation strategy is needed to improve outcomes and reduce avoidable complications.

Level of evidence

Level IV, Systematic reviews.

The cement-bone bond is weaker than cement-cement bond in cement-in-cement revision arthroplasty. A comparative biomechanical study

This study compares the strength of the native bone-cement bond and the old-new cement bond under cyclic loading, using third generation cementing technique, rasping and contamination of the surface of the old cement with biological tissue. The possible advantages of additional drilling of the cement surface is also taken into account. Femoral heads from 21 patients who underwent a total hip arthroplasty performed for hip arthritis were used to prepare bone-cement samples. The following groups of samples were prepared. A bone—cement sample and a composite sample of a 6 weeks old cement part attached to new cement were tested 24 hours after preparation to avoid bone decay. Additionally, a uniform cement sample was prepared as control (6 weeks polymerization time) and 2 groups of cement-cement samples with and without anchoring drill hole on its surface, where the old cement polymerized for 6 weeks before preparing composite samples and then another 6 weeks after preparation. The uniaxial cyclic tension-compression tests were carried out using the Zwick-Roell Z020 testing machine. The uniform cement sample had the highest ultimate force of all specimens (n = 15; R_m = 3149 N). The composite cement sample (n = 15; R_m = 902 N) had higher ultimate force as the bone-cement sample (n = 31; R_m = 284 N; p <0.001). There were no significant differences between composite samples with 24 hours (n = 15; R_m = 902 N) and 6 weeks polymerization periods (n = 22; R_m = 890 N; p = 0.93). The composite cement samples with drill hole (n = 16; R_m = 607 N) were weaker than those without it (n = 22; R_m = 890 N; p < 0.001). This study shows that the bond between the old and new cement was stronger than the bond between cement and bone. This suggests that it is better to leave the cement that is not loosened from the bone and perform cement in cement revision, than compromising bone stock by removal of the old cement with the resulting weaker cement-bone interface. The results support performing cement-in-cement revision arthroplasty The drill holes in the old cement mantle decrease cement binding strength and are not recommended in this type of surgery.

The cement-in-cement technique is a reliable option in hip arthroplasty revision surgery: a systematic review

INTRODUCTION

The cement-in-cement technique for revision hip arthroplasty has many potential advantages and has recently gained widespread interest but still lacks evidence to support it. Our aim was to examine the surgical and patient-reported outcomes after cement-in-cement revision hip arthroplasty.

MATERIALS AND METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE databases were searched up to February 2019 for original studies reporting the outcomes of revision hip arthroplasty surgeries using the cement-in-cement technique. The methodological quality was assessed using the methodological index for non-randomized studies scale.

RESULTS

Sixteen non-comparative studies met the eligibility criteria, comprising 1899 hips in 1856 patients (72.2 mean age, 37% male), with a mean follow-up of 7.2 years. Most studies reported only primary revisions and focused on the stem component. Intraoperative complications such as femoral or acetabular fractures (5.3%) were low and easily manageable with no relevant sequelae, as were dislocation rates (2.8% of uncomplicated events and 1.6% of cases requiring re-revision). Failure (considered if there was aseptic loosening of the cement-in-cement revised component, 2%), re-revision (9.3%), implant survival and late complication rates were favourable. Functional patient-reported outcomes showed an overall improvement above the minimal clinically important difference at final follow-up.

CONCLUSION

The cement-in-cement technique is a viable option for hip arthroplasty revision surgery with low intraoperative and late complication rates, dislocations and immediate post-operative morbidity, resulting in good functional patient-reported outcomes and favourable medium-term implant survival.

Cement-in-cement revision of the femoral stem

Aims

Compared with primary total hip arthroplasty (THA), revision surgery can be challenging. The cement-in-cement femoral revision technique involves removing a femoral component from a well-fixed femoral cement mantle and cementing a new stem into the original mantle. This technique is widely used and when carried out for the correct indications, is fast, relatively inexpensive and carries a reduced short-term risk for the patient compared with the alternative of removing well-fixed cement. We report the outcomes of this procedure when two commonly used femoral stems are used.

Patients and Methods

We identified 1179 cement-in-cement stem revisions involving an Exeter or a Lubinus stem reported to the Swedish Hip Arthroplasty Register (SHAR) between January 1999 and December 2015. Kaplan-Meier survival analysis was performed.

Results

Survivorship is reported up to six years and was better in the Exeter group (91% standard deviation (sd) 2.8% versus 85% sd 5.0%) (p = 0.02). There was, however, no significant difference in the survival of the stem and risk of re-revision for any reason (p = 0.58) and for aseptic loosening (p = 0.97), between revisions in which the Exeter stem (94% sd 2.2%; 98% sd 1.6%) was used compared with those in which the Lubinus stem (95% sd 3.2%; 98% sd 2.2%) was used. The database did not allow identification of whether a further revision was indicated for loosening of the acetabular or femoral component or both.

Conclusion

The cement-in-cement technique for revision of the femoral component gave promising results using both designs of stem, six years post-operatively. Cite this article: Bone Joint J 2017;99-B(4 Supple B):27–32.

Revision Total Hip Arthroplasty Using the Cement-in-Cement Technique

The cement-in-cement technique is useful in the setting of revision total hip arthroplasty (THA), especially to gain acetabular exposure, change a damaged or loose femoral component, or change the version, offset, or length of a fixed femoral component. The goal of this retrospective study was to assess the clinical and radiographic characteristics of revision THA using the cement-in- cement technique. Between 1971 and 2013, a total of 63 revision THAs used an Omnifit (Osteonics, Mahwah, New Jersey) or Exeter (Howmedica, Mahwah, New Jersey) stem and the cement-in-cement technique at the senior author's institution. Aseptic loosening (74%) was the predominant preoperative diagnosis followed by periprosthetic fracture (14%), instability (8%), and implant fracture (6%). Mean clinical follow-up was 5.5±3.8 years. The Harris Hip Score had a statistically significant increase of 18.5 points (P<.001) after revision THA using the cement-in-cement technique. There were 13 returns to the operating room, resulting in an overall failure rate of 21%. Eleven (18%) cases required revision THA, but only 1 (2%) revision THA was for aseptic removal of the femoral component. All other femoral implants had no evidence of component migration, cement mantel fracture, or circumferential lucent lines at final follow-up. The patients who underwent cement-in-cement revision THA at the senior author's institution had good restoration of function but a high complication rate. [Orthopedics. 2017; 40(2):e348-e351.].