In vitro performance of intramedullary cement restrictors in total hip arthroplasty

Are current rates of uncemented fixation in total hip arthroplasty supported by the literature? An update on the uncemented paradox

The optimal fixation method in total hip arthroplasty (THA) remains controversial. Initial concerns related to the long-term performance of cement fixation as well as cement disease led to the development of cementless implants, and registry data has indicated that the use of this type of fixation has increased in recent years. However, data from these same registries has not shown any improvement in outcomes when compared to cement fixation. On the contrary, while similar outcomes are seen when comparing these fixation types in younger patients (<70 years of age), cementless fixation has shown increased implant failure and revision rates in elderly patients (>70 years of age). Given the increased projected volume of THA in the United States over the next decade, it is important to utilise available data to make clinical decisions that minimise not only individual patient harm, but also the burden on the healthcare system itself. This review provides an overview of currently available outcomes data comparing cement and cementless fixation, as well as an updated analysis of current trends in fixation use in THA. We furthermore provide a comprehensive technique guide to help surgeons optimise cement fixation of the femoral component for THA and hemiarthroplasty.

Comparison of osteolysis around 3 different cement restrictors in total hip arthroplasty

BACKGROUND AND AIM

Several studies reported osteolysis around polyethylene glycol/polybutylene terephthalate (PEG/PBT) based femoral cement restrictors. Our goal was to evaluate and compare osteolysis around 3 different plug designs: the slow biodegradable PEG/PBT cement restrictor; the fast biodegradable gelatin cement restrictor; and the non-biodegradable polyethylene plug.

PATIENTS AND METHODS

In a retrospective multicentre cohort study chart data were extracted of patients who received a total hip arthroplasty between 2008 and 2012. A total of 961 hips were included. Cortical ratio between inner and outer cortices at the centre of the plug was measured on routine postoperative follow-up moments. Median follow up of all 3 hospitals was 3.5 years (1.4-7.3). The primary outcome was evidence of osteolysis (i.e. the difference in cortical ratio [CR]) on anteroposterior (AP) radiographs at final follow-up.

RESULTS

Progressive osteolysis was found around the PEG/PBT cement restrictor represented by a significantly increasing cortical ratio (ΔCR 0.067 (95% CI, 0.063-0.071). Distance from tip prosthesis to plug and size of the plug were found to be independent factors in predicting increased cortical ratio.

CONCLUSIONS

Our multicentre cohort shows increase of cortical ratio around the PEG/PBT cement restrictor which progresses over time. Physicians should be aware of this fact and are advised to intensify follow-up of patients who received this cement restrictor.

Bone cement implantation syndrome in hip arthroplasty: Frequency, severity and prevention

INTRODUCTION

Cemented femoral implants incur a serious risk of potentially fatal accidents in case of bone cement implantation syndrome (BCIS). As French data are sparse regarding this issue, Orthorisq, the official accreditation body for orthopedic surgeons, conducted an inter-professional survey: 1) to assess the frequency of BCIS, 2) to analyze risk factors related to the patient and to professional practices, and 3) to set out guidelines to reduce frequency and/or severity.

HYPOTHESIS

French data on BCIS are underestimated and need updating to ease communication between colleagues.

MATERIAL AND METHOD

In 2019, Orthorisq ran a survey of its members' practices and a "mirror" survey of anesthesiologists. In the decade from 2009 to 2018, the 775 respondent orthopedic surgeons, both occasional and systematic "cementers", reported their experience with a declared annual rate of 80,112 arthroplasties, including 63,799 (79.6%) in scheduled surgery. Some of the survey questions concerned cementing technique. With the help of the French College of Anesthesia and Intensive Care Medicine, 305 anesthesiologists responded to the mirror survey.

RESULTS

The 776 orthopedic surgeons reported 1896 cementing accidents with 387 deaths during the study decade. Accidents were 6-fold more frequent in traumatology than in scheduled orthopedic surgery (0.71% versus 0.12%) and, more importantly, were more serious: mortality was 10-fold higher (0.17% versus 0.017% [p<0.001]). Certain "tricks and tips" intended to improve cementing quality, such as a dedicated system and especially a plug, significantly increased the risk of BCIS (p<0.001). Over the same period, the 305 anesthesiologists had been involved in 490 cementing accidents; 88 (29%) had been faced by at least 1 death, most often in emergency settings (60/28). While 753 surgeons (96%) reported warning the anesthetists and 571 (74%) waited for agreement before cementing, only 109 (36%) and 124 (41%) anesthetists reported being systematically alerted to cementing and implant reduction, respectively. The rate of serious accidents was 0.19% and mortality was 0.05%, for a cumulative probability of 0.24% per year. Extrapolated to the data of the ATIH Technical Agency of Hospitalization Information and subtracting arthroplasties by "never-cementers", these figures indicate 311 accidents with 65 deaths in femoral BCIS for 2018.

DISCUSSION

In scheduled surgery, BCIS was exceptional, but the rate in traumatology was much higher. Certain techniques intended to improve femoral cementing quality actually increased the risk of BCIS; in high-risk patients, especially in traumatology, non-cemented femoral implants or else a 1st-generation cementing technique should therefore be preferred. Prevention of BCIS and/or reduction of severity require identification of at-risk patients and good communication between surgeons and anesthesiologists, especially at the various steps of the checklist.

LEVEL OF EVIDENCE

IV; case series.

Cement arteriovenogram after hip arthroplasty

Modern cement implantation techniques during hip arthroplasty rely on high intramedullary pressures which can result in cement extrusion towards femoral nutrient vessels, and thus, the occurrence of a particular image in postoperative radiographs (bone cement arterio-venogram). We report a case series of 14 patients in whom a bone cement arterio-venogram was observed after undergoing a cemented hip arthroplasty. No local or systemic complications developed after cementing nor during a mean follow-up of three years. Bone cement arterio-venogram is a radiologic sign that indicates a good cement pressurisation during surgery and is not associated to medical complications or periprosthetic femoral fractures.

Charnley femoral cemented stem with a permeable and resorbable cement restrictor and low-viscosity cement - Clinical and radiographical evaluation of 100 cases at a mean follow-up of 6.55 years

INTRODUCTION

In 1979, in his first book dealing with low-friction arthroplasty (LFA), Charnley highlighted the use of a cement restrictor. Breusch and Malchau described in 2005 the "second-generation cementing technique." The main objective of this study was to report on the clinical survival of 100 cases of Charnley femoral component implanted in 2007 and 2008 using a permeable and resorbable cement restrictor and a low-viscosity antibiotic-loaded cement. The secondary objectives were to analyze the complications and side effects and the accuracy of the device positioning.

MATERIAL AND METHODS

This was a monocentric retrospective review of a prospectively compiled database. Diaphyseal restrictor was biodegradable and permeable to gas, blood, and fluids to avoid intramedullary over pression during cementation. The cement was a low-viscosity antibiotic-loaded cement. Among 3555 patients, we selected the first continuous 100 cases of patients where we implanted the device. Survival probability was computed according to Kaplan-Meier method.

RESULTS

Mean follow-up was 6.55 ± 2.6 (range 1-11). Considering femoral component revision as the endpoint, survival rate was 100%. No patients died intraoperatively, none in the first month and the first year after surgery. No early periprosthetic fractures have been reported.

DISCUSSION

As described initially by Charnley, the use of a cement restrictor was highly recommended through the different generations of cementing techniques. Hypotensive episodes and cardiac arrest have been reported during cement insertion. In our series, we did not deplore any adverse effect related to the cementation.

CONCLUSION

Our study demonstrates a 100% survival rate of a cemented femoral component without adverse effects when using routinely a resorbable and permeable cement restrictor and a low-viscosity cement. Bone cement is still a fantastic ally for the surgeon and the patients.

Bone Cement Implantation Syndrome: Key Concepts for Perioperative Nurses

Bone cement implantation syndrome (BCIS) is a potentially fatal complication of orthopedic surgeries that use cement. The symptoms of BCIS occur primarily during femoral fracture repairs, but this complication has been reported in a wide variety of cemented procedures. Clinical presentation of this syndrome begins as a cascade with hypoxia and hypotension; if it is not reversed, it ends with right-sided heart failure and cardiac arrest. This syndrome usually occurs at cementation, prosthesis insertion, joint reduction, or tourniquet deflation, and should be treated with aggressive resuscitation and supportive care. This article provides a comprehensive explanation of bone cement, the identification and management of BCIS, and the roles of the perioperative team in the event of cardiopulmonary collapse. It includes a case study that can be used as an educational tool for simulation, mock drills, or staff meetings; it also may be used as a framework for creating policies.

Pulmonary cement embolism in a child following total elbow replacement for primitive neuroectodermal tumour (PNET) of the humerus

Pulmonary bone cement embolism (PCE) is an uncommon event occurring after implantation of polymethylmethacrylate (PMMA) in orthopaedic surgeries involving adult patients, more so in the elderly. Its incidence in the paediatric population is extremely rare. We herein describe a case of PCE in a 15-year-old girl, 9 days after she underwent total elbow replacement with PMMA placement for a primitive neuroectodermal tumour (PNET) of the distal humerus. This report describes the occurrence of a common post-operative complication of bone cement embolism in an uncommon scenario of total elbow replacement for a bone tumour in a child, which masqueraded initially as acute pneumonitis.

The Relative Merits of Cemented and Uncemented Prostheses in Total Hip Arthroplasty

The results of modern cemented and uncemented total hip arthroplasties are outstanding and both systems have their advantages and disadvantages. This paper aims to examine the designs of different types of prostheses, some history behind their development and the reported results. Particular emphasis is placed on cemented stem design and the details of cementing technique.

Bone cement

The knowledge about the bone cement is of paramount importance to all Orthopaedic surgeons. Although the bone cement had been the gold standard in the field of joint replacement surgery, its use has somewhat decreased because of the advent of press-fit implants which encourages bone in growth. The shortcomings, side effects and toxicity of the bone cement are being addressed recently. More research is needed and continues in the field of nanoparticle additives, enhanced bone-cement interface etc.

Osteolysis in cemented total hip arthroplasty involving the OptiPlug cement restrictor: more than an incident?

The case report of a severe osteolytic reaction surrounding the OptiPlug cement restrictor in a 74-year-old male patient initiated a retrospective case series and closer investigation into the OptiPlug and its active compound, PolyActive. Not only did we find several cases of severe osteolysis in our own study population of 284 patients, several articles have lately described potential harmful side effects of the PolyActive material in humans. Although none of the articles have been based on large databases, we cannot guarantee the safety of this product. More research would help in our understanding of this phenomenon. Until then, we cannot recommend the use of the OptiPlug cement restrictor.

A novel technique for femoral canal occlusion during cement pressurization in proximal femoral arthroplasty

We describe a novel technique for occluding the femoral canal distal to the isthmus during proximal femoral arthroplasty. Synthetic bone models were reamed and sectioned to simulate loss of the proximal femur. Two experimental conditions were used. The first used no restrictor to act as a control. The second used calcium sulphate pellets impacted in distal femoral canal. A 100 × 12 mm Limb Preservation System stem (DePuy, Leeds, UK) was used in all experiments. We recorded cement pressure, leakage of cement, and penetration of cement into the femoral condyles. The calcium sulphate pellets prevented cement leakage, enabled higher cementing pressures, and prevented penetration of the cement into the femoral condyles. We would recommend this technique in cases where loss of proximal femoral bone loss requires the use of a cemented proximal femoral replacement.

In vivo failure analysis of intramedullary cement restrictors in 100 hip arthroplasties

BACKGROUND

We occasionally noticed excessive distal plug position in our clinical routine of cemented hip arthroplasties. We therefore performed an analysis of risk factors for migration of a biodegradable intramedullary gelatine plug.

PATIENTS AND METHODS

The performance of a cement restrictor was studied in 100 consecutive cemented total hip arthroplasties implanted with third-generation cementing techniques. In a radiographic analysis anatomical parameters, cement mantle quality, and mechanisms and factors for restrictor failure were evaluated.

RESULTS

40 restrictors showed inadequate performance: 5 cases of tilting, 22 cement leakages, 16 excessive migrations, 2 excessive migrations plus leakages, and 1 case of leakage plus tilting. excessive migration (< 5 cm) was more common in large intramedullary canals (p = 0.04) and cement leakage was more common in patients with a proximally located isthmus (p = 0.04). Half of the hips showed a complete or almost complete filling of the intramedullary cavity, which was more often found in operations carried out by experienced surgeons.

INTERPRETATION

A more reliable plug design should be considered for patients with wide intramedullary canals and a high isthmus, to minimize the risk of plug migration and poor cement mantle quality.

Cement restrictor function below the femoral isthmus

Cement restrictors rely on achieving an interference fit with the wall of the medullary canal. Depending on the design of the cement restrictor, the intramedullary fit may be compromised as the femur starts to widen distally. Three different designs of cement restrictor were identified; universal, press-fit, and expandable. We determined which design of cement restrictor could resist the greatest pressures in a closed column of cement. Additionally, we recorded leakage of cement past the restrictor. We reamed synthetic femora to recreate the normal distal flare of the femur below the femoral isthmus. After inserting the cement restrictor, low-viscosity cement was gradually pressurized using an electronically controlled pneumatic ram. We then simultaneously recorded cement pressure above the cement restrictor and displacement of the cement restrictor. There was variation in the performance of the cement restrictors. The expandable cement restrictors resisted the greatest pressures. The resorbable expandable (REX Cement Stop) and press-fit cement restrictors reliably prevented cement leakage. The press-fit and universal restrictors failed at low pressures when deployed below the isthmus. The choice of cement restrictor may need to be modified if preoperative templating indicates the restrictor will sit below the femoral isthmus.

Performance of 3 gelatine-based resorbable cement plugs: a study on 15 synthetic femurs and a prospective randomized study on 103 patients

BACKGROUND

Intramedullary plugs are key factors in improving cement fixation of the femoral component. We investigated the performance of 3 commercially available resorbable cement restrictors in vitro and in vivo.

METHODS

We measured the migration of the SEM II, the C-plug, and the REX plug in 15 Sawbones synthetic femurs and in 103 patients during total hip surgery. Cement pressures were also measured distally and proximally in vitro.

RESULTS AND INTERPRETATION

Our in vitro results showed poor performance of the C-plug compared with the REX and SEM II plugs. In vivo, the mean migration was least for the SEM plug and most for the C-plug. The smaller sizes performed significantly better than the larger ones for all 3 plug types. The overall in vivo performance of all 3 plug types was unsatisfactory. Differences between the SEM II and REX plugs were small and therefore not significant. The SEM II performed better than the REX, the former being much cheaper and easier to insert. The Rex plug looks promising; however, the insertion device must be improved for better results. The C-plug proved to be unstable.

Total joint replacement in the dog

Total joint replacement has evolved over the past 50 years from a concept that was first attempted in people suffering from osteoarthritis to a commonly applied practice in veterinary medicine. Although many questions have been answered, several controversies still exist, with many implant and technical options being explored. Currently, total hip and elbow replacement are commercially available options viable for use in dogs. These options are detailed in this article. Joint replacement for other canine joints (ie, knee, hock, shoulder) that develop osteoarthritis likely will be developed in the near future.

The technique of cemented total hip replacement

Cement fixation has a 30-year history in total hip arthroplasty. Cement fixation is a durable and reproducible means of fixation in a variety of hips. A key determinant to a cement mantle's longevity is the technique of cementing. This article reviews what has been learned in the past and outlines the state of the art in cement technique today.

New technology in cemented total hip arthroplasty

The long-term results of total hip arthroplasty (THA) are predicated by excellent surgical techniques. New technology offers the hope of improving outcomes by providing to surgeons tools that make surgical procedures predictable. Techniques that improve the bone-cement-prosthesis composite should enhance long-term fixation. Less invasive surgical techniques that allow rapid recovery from THA have been recently described. Image-guided surgery may enable surgeons to accurately reconstruct the arthritic hip and improve outcomes.

Insertion of an expandable cement restrictor reduces intramedullary fat displacement

The insertion of an intramedullary cement restrictor can lead to the same pathophysiologic reactions that are well described as fat embolism syndrome after cement and stem implantation. Fat and marrow are forced into the draining veins of the femur. In this study, we compared the extrusion of intramedullary contents produced by the insertion of a commonly used gelatin (Biostop G/IMSET) and a new expandable cement restrictor (REX Cement Stop) in 7 paired, fresh-frozen femora. A further 9 pairs were used to evaluate the function of a custom-made application instrument, which allowed for suction during plug (Biostop G/IMSET) insertion. The oversized restrictor produced, on average, twice as much fat as the expandable restrictor (P = 0.0156). The gelatin plug with additional suction was not associated with reduced fat extrusion, because the suction device in its current design failed because of obstruction in most cases. The expandable restrictor showed favorable characteristics and has the potential to reduce the risk of fat embolism.