Effect of long-term physiological activity on the long-term stem stability of cemented hip arthroplasty: in vitro comparison of three commercial bone cements

Standard and line-to-line cementation of a polished short hip stem: Long-term in vitro implant stability

The current trend is toward shorter hip stems. While there is a general agreement on the need for a cement mantle thicker than 2 mm, some surgeons prefer line-to-line cementation, where the mantle has only the thickness provided by the cement-bone interdigitation. The aim of this study was to assess if a relatively short, polished hip stem designed for a standard cementation can also be cemented line-to-line without increasing the risk of long-term loosening. Composite femurs with specific open-cell foam to allow cement-bone interdigitation were used. A validated in-vitro biomechanical cyclic test replicating long-term physiological loading was applied to femurs where the same stem was implanted with the Standard-mantle (optimal stem size) and Line-to-line (same rasp, one-size larger stem). Implant-bone motions were measured during the test. Inducible micromotions never exceeded 10 μm for both implant types (differences statistically not-significant). Permanent migrations ranged 50-300 μm for both implant types (differences statistically not-significant). While in the standard-mantle specimens there was a pronounced trend toward stabilization, line-to-line had less tendency to stabilize. The cement cracks were observed after the test by means of dye penetrants: The line-to-line specimens included the same cracks of the standard-mantle (but in the line-to-line specimens they were longer), and some additional cracks. The micromotions and cement damage were consistent with those observed in-vitro and clinically for stable stems, confirming that none of the specimens became dramatically loose. However, it seems that for this relatively short polished stem, standard-mantle cementation is preferable, as it results in less micromotion and less cement cracking. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2736-2744, 2018.

METHOD TO ANALYZE THE FATIGUE CRACKS IN ACRYLIC BONE CEMENT

Acrylic bone cement is a poly(methyl methacrylate)-based material that ensures short-term stability of orthopedic implants after surgery. Its long-term performance can be affected by many factors (e.g., composition, cement mixing and delivery method, temperature, humidity). Furthermore, patient activities produce a spectrum of cyclic loads that generate microdamage within the acrylic bone cement mantle. Therefore, pre-clinical studies on fatigue damage of acrylic bone cements are essential for predicting the long-term stability of cemented implants. There are several methods for analyzing damage of acrylic bone cement. However, they present a number of limitations. The aim of this study was to validate the use of a high-resolution scanner to analyze the presence of microcracks in acrylic bone cement. The proposed method met predetermined criteria to overcome limitations of previous methods, ensuring approximate spatial resolution of 5 microns, reduction of image acquisition time, and reduction of artifacts due to operator and/or environment during image acquisition. Additionally, the described method was applied to three types of acrylic bone cement specimens that previously were subjected to a fatigue test. The presented method enables the accurate assessment of fatigue damage induced during cycling loading, including quantification of the number, length, type and position of cement cracks.

Effect of undersizing on the long-term stability of the Exeter hip stem: A comparative in vitro study

BACKGROUND

Even for clinically successful hip stems such as the Exeter-V40 occasional failures are reported. It has been reported that sub-optimal pre-operative planning, leading to implant undersizing and/or thin cement mantle, can explain such failures. The scope of this study was to investigate whether stem undersizing and a thin cement mantle are sufficient to cause implant loosening.

METHODS

A comparative in vitro study was designed to compare hip implants prepared with optimal and smaller than optimal stem size. Exeter-V40, a highly polished cemented hip stem, was used in both cases. Tests were carried out simulating 24 years of activity of active hip patients. A multifaceted approach was taken: inducible and permanent micromotions were recorded throughout the test; cement micro-cracks were quantified using dye penetrants and statistically analyzed.

FINDINGS

The implants with an optimal stem size withstood the entire mechanical test, with low and stable inducible micromotions and permanent migrations during the test, and with moderate fatigue damage in the cement mantle after test completion. Conversely, the undersized specimens showed large and increasing micromotions, and failed after few loading cycles, because of macroscopic cracks in the proximal part of the cement mantle. While results for the optimal stem size are typical for stable hip stems, those for the undersize stem indicate a critical scenario.

INTERPRETATION

These results confirm that even a clinically successful hip prosthesis such as the Exeter-V40 is prone to early loosening if a stem smaller than the optimal size is implanted.