Revision total hip replacement using the cement-in-cement technique for the acetabular component

Partial retention of the acetabular cement mantle in aseptic revision hip arthroplasty: is it a viable option?

INTRODUCTION

Choosing the most appropriate reconstruction method when addressing a cemented cup at hip revision surgery can be a difficult decision. The aim of this study is to look into the practice and results of retaining a well-fixed medial acetabular cement mantle while removing loose superolateral cement. This practice goes against a preconceived principle that if some of the cement is loose it must all be removed. So far, no significant series looking at this is available in the literature.

METHODS

We assessed a cohort of 27 patients in our institution where this practice was carried out and assessed their outcomes clinically and radiographically.

RESULTS

Of the 27 patients, 24 had follow-up ⩾2 years (2.9-17.8, mean 9.3 years). There was 1 subsequent revision for aseptic loosening at 11.9 years, 1 first-stage revision of both stem and cup for infection at 1 month, and 2 patients died without a 2-year review. 2 patients did not have radiographs available for review. 2 of the 22 patients with radiographs available had changes in lucent lines, which were not clinically significant.

CONCLUSION

Based on these results we conclude that retaining well-fixed medial cement during socket revision is a viable reconstruction option in carefully selected cases.

Mixed manufacturer dual mobility bearing and the Exeter V40 Stem: is it safe? Short-term results in primary and revision hip replacement

The aim is to review clinical and radiological outcomes for all cases of primary and revision THA, combining a cemented stem (Exeter V40) with a dual mobility component from a different manufacturer (SERF Novae), to evaluate whether concerns regarding mixing components from different manufacturers are justified. We identified 72 hip replacements performed between May 2010 and December 2015 using the SERF Novae dual mobility cup with an Exeter V40 stem, the majority of which were cemented (90%) and revisions (58%). Patients were evaluated clinically and radiologically at a minimum of two years. There were five (6.9%) dislocations; three (4.2%) requiring revision - one of which was an intra-prosthetic disarticulation and two infections. No cases were lost to follow-up and 49 surviving cases were reviewed at a mean of 4.0 (range 1.8-8.1) years following surgery. Pain and functional outcome scores all improved. There were no radiological failures and no revisions for aseptic loosening of stem or cup. The combination of Exeter cemented stem with a dual mobility bearing from a different manufacturer results in acceptable short-term outcomes in terms of hip stability, revision rates and patient-reported measures.

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 All-Polyethylene Tibial Revision: A Report of 3 Cases

CASE

Debonding of the tibial component of total knee arthroplasty is a known complication that is typically treated with revision surgery, most commonly revision to a metal-backed tibial component with or without stems. Here, we present 3 cases of tibial component debonding revised to all-polyethylene tibial components with a cement-in-cement technique.

CONCLUSION

In instances of tibial component debonding, if specific criteria are met, revising to an all-polyethylene tibia with retention of the primary cement mantle is an alternative to revision surgery with cement extraction and implantation of a modular metal-backed tibia.

Two stage cementation and screw augmentation of large acetabular defects in low demand patients: Early results and surgical technique

INTRODUCTION

The reconstruction of large acetabular defects in revision hip arthroplasty represents a challenge to the surgeon and increases the complexity of the case. There are different options to overcome the problem of acetabular deficiency. In the elderly low demand patients, the main objective of revision surgery is to provide pain relief, allow immediate full weight bearing, and an early return to function.

METHODS

This article presents our experience in acetabular revision surgery using a novel technique of two stage cementation and screw augmentation in low demand patients. We report on the surgical technique and present the early results in 10 patients.

RESULTS

There were 6 females and 4 males with average age of 83.8 years. Patients were followed up for an average of 18.1 months. All patients were pain free and full weight bearing at the time of the final follow up with radiographs showing maintenance of implant position. None of the patients underwent revision surgery and there were no radiographic signs of failure detected in the early follow-up period.

CONCLUSION

This is a suitable technique in the management of large acetabular defects in revision hip arthroplasty, especially in the low demand patient population. It is a simple cost-effective technique that reduces the complexity of the acetabular revision, operative time, and morbidity associated with prolonged complex revision surgery.

Even "Cementless" Surgeons Use Cement

BACKGROUND

Patients presenting with hip arthritis have huge variability in anatomy, bone quality, and functional expectation. These can contribute to a varying degree of complexity on both the femoral and acetabular sides. Surgeons should be aware of all the various options in fixation, bearing surface, and surgical technique.

METHODS

In this article, based on a presentation given at the recent American Association of Hip and Knee Surgeons meeting in Dallas, we will discuss why and how cemented fixation can, and indeed should, be considered when making decisions regarding how a primary, complex primary, or revision hip arthroplasty should be performed.

RESULTS

We will review the evidence, surgical technique, and indications for cemented fixation in primary and complex primary surgery. In addition, we will discuss the potential benefits at revision of previous cemented fixation.

CONCLUSION

We hope to support the concept that even cementless surgeons should also use cement.

Predictive Model of Surgical Time for Revision Total Hip Arthroplasty

BACKGROUND

Maximizing operating room utilization in orthopedic and other surgeries relies on accurate estimates of surgical control time (SCT). A variety of case and patient-specific variables can influence the duration of surgical time during revision total hip arthroplasty (THA). We hypothesized that these variables are better predictors of actual SCT (aSCT) than a surgeon's own prediction (pSCT).

METHODS

All revision THAs from October 2008 to September 2014 from one institution were accessed. Variables for each case included aSCT, pSCT, patient age, gender, body mass index, American Society of Anesthesiologists Physical Status class, active infection, periprosthetic fracture, bone loss, heterotopic ossification, and implantation/explantation of a well-fixed acetabular/femoral component. These were incorporated in a stepwise fashion into a multivariate regression model for aSCT with a significant cutoff of 0.15. This was compared to a univariate regression model of aSCT that only used pSCT.

RESULTS

In total, 516 revision THAs were analyzed. After stepwise selection, patient age and American Society of Anesthesiologists Physical Status were excluded from the model. The most significant increase in aSCT was seen with implantation of a new femoral component (24.0 min), followed by explantation of a well-fixed femoral component (18.7 min) and significant bone loss (15.0 min). Overall, the multivariate model had an improved r² of 0.49, compared to 0.16 from only using pSCT.

CONCLUSION

A multivariate regression model can assist surgeons in more accurately predicting the duration of revision THAs. The strongest predictors of increased aSCT are explantation of a well-fixed femoral component, placement of an entirely new femoral component, and presence of significant bone loss.

The Exeter Contemporary flanged cemented acetabular component in primary total hip arthroplasty

Aims

We report on the outcome of the Exeter Contemporary flanged cemented all-polyethylene acetabular component with a mean follow-up of 12 years (10 to 13.9). This study reviewed 203 hips in 194 patients. 129 hips in 122 patients are still in situ; 66 hips in 64 patients were in patients who died before ten years, and eight hips (eight patients) were revised. Clinical outcome scores were available for 108 hips (104 patients) and radiographs for 103 hips (100 patients).

Patients and Methods

A retrospective review was undertaken of a consecutive series of 203 routine primary cemented total hip arthroplasties (THA) in 194 patients.

Results

There were no acetabular component revisions for aseptic loosening. Acetabular revision was undertaken in eight hips. In four hips revision was necessitated by periprosthetic femoral fractures, in two hips by recurrent dislocation, in one hip for infection and in one hip for unexplained ongoing pain. Oxford and Harris hip scores demonstrated significant clinical improvement (all p < 0.001). Radiolucent lines were present in 37 (36%) of the 103 acetabular components available for radiological evaluation. In 27 of these, the line was confined to zone 1. No component had migrated.

Conclusion

Kaplan–Meier survivorship, with revision for aseptic loosening as the endpoint, was 100% at 12.5 years and for all causes was 97.8% (95% confidence interval 95.6 to 100) when 40 components remained at risk. The Exeter Contemporary flanged cemented acetabular component demonstrates excellent survivorship at 12.5 years. Take home message: The Exeter Contemporary flanged cemented acetabular component has excellent clinical outcomes and survivorship when used with the Exeter stem in total hip arthroplasty. Cite this article: Bone Joint J 2016;98-B:307–12.

Clinical and radiographic outcomes of acetabular impaction grafting without cage reinforcement for revision hip replacement: a minimum ten-year follow-up study

Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan-Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.

Surgical management of recurrent dislocation after total hip arthroplasty

Dislocation is a major complication of total hip arthroplasty (THA), whose frequency has been unaffected by improvements in surgical techniques and implants. The dislocation rate depends on multiple factors related to the patient, hip disease, and surgical procedure and is therefore also dependent on the surgeon. The many published studies on THA dislocation, its causes, and its treatment have produced conflicting results. The objective of this work is to review the management of THA dislocation, which is a severe event for both the patient and the surgeon. This lecture starts with a brief review of data on THA dislocation rates and the many factors that influence them. Emphasis is then put on the evaluation for a cause and, more specifically, on the challenges raised by detecting suboptimal cup position. Next, reported techniques for treating THA dislocation and the outcomes of each are discussed. Finally, a management strategy for patients selected for revision surgery is suggested.