Cementation in total hip arthroplasty: history, principles, and technique

Abstract

Total hip arthroplasty (THA) is a remarkably successful operation that has grown rapidly its utilization. Early modern THA constructs as developed by Sir John Charnley featured cemented femoral stems and acetabular components. The technique of cementing components for THA has evolved over time. Modern acetabular preparation requires exposure of the subchondral bone with appropriate cement penetration into the trabecular bone, whereas femoral preparation requires cleaning of the canal, cement restrictor placement, retrograde filling, and pressurization of the cement. When used appropriately, these techniques result in excellent long-term survivorship of implants and are also widely considered to be the ideal method of fixation for hip fractures. The purpose of this article to review the history, properties, techniques, and outcomes of bone cement utilization in THA.

Keywords: arthroplasty; bone cement; surgical technique; total hip replacement.

Figure 1

Initial exposure of the acetabulum during a total hip replacement via a posterior approach.

Figure 2

Appearance of the acetabulum following reaming.

Figure 3

Appearance of the acetabulum following drill hole placement.

Figure 4

Example of the drill utilized for acetabulum cement hole creation.

Figure 5

Bone cement placed into acetabulum after preparation.

Figure 6

Pressurization of cement in the acetabulum with surrounding extruded cement.

Figure 7

Example of an all-polyethylene acetabular component.

Figure 8

Acetabular component insertion using a holder.

Figure 9

Pressurization of acetabular component with appropriate version and inclination according to the surrounding anatomical landmarks after excess cement has been cleared.

Figure 10

Final position of the cemented acetabular component with removal of excess cement.

Figure 11

Example of a commercially available cement preparation kit. The components include (from top to bottom): femoral sponge with suction attachment, disposable cement sculps, femoral canal brush, universal and small canal restrictors, and a disposable restrictor inserter (BioPrep™ Bone Preparation Kit, Stryker Instruments).

Figure 12

Mechanical cleaning of the femoral canal using either (A) manual brush or (B) a brush-tipped pulsed lavage (Interpulse Femoral Canal Brush, Styker Instruments).

Figure 13

A cement restrictor attached to the inserter. The desired depth of the canal restrictor is marked out against a set point of the femoral stem (e.g. collar or shoulder) to allow for a 1.5–2 cm distal cement mantle.

Figure 14

Drying the femoral canal. The femoral canal can be dried with (A) a femoral sponge with suction attachment or (B) by packing with epinephrine-soaked gauze.

Figure 15

Instruments required for cementing the femoral stem. These should be placed in order of use on the Mayo stand and include (from left to right): curettes and elevator to scrape excess cement, a stem and insertion handle, a nasogastric tube to remove blood from canal during insertion, and a large clamp to remove packed sponges from canal.

Figure 16

Testing of the phase of cement curing prior to use. (A) Cement that is not ready for insertion will have a runny or sticky consistency. (B) Cement that is for insertion will have a doughy consistency with wrinkling on the surface and not stick to the surgical glove.

Figure 17

Pressurization of the femoral cement. After retrograde insertion of femoral cement using a cement ‘gun’, the long-attachment nozzle is broken off a tight seal created using the gray pressurizer (Universal pressurizer, DePuy Orthopaedics, Warsaw, IN, USA) before further injecting cement.

Figure 18

Insertion of the femoral stem using an insertion handle. The surgeon’s thumb is held over the medial calcar to prevent cement extrusion and help pressurization.