Ortho Oracle - orthopaedic operative atlas
Home » Joints » Hip » Cemented Femoral Stems

Cemented Femoral Stems

- See: Total Hip Replacement Menu:
         - Cemented Femoral Component: Loosening:
         - Collar: in THR
         - Optimal Cementing Technique
         - Removal of Cemented Femoral Stems:

- Indications:
    - cemented femoral stems probably remain gold standard for total hip arthroplasty;
    - most indicated in older patients (more than 65 yrs), but are also used in younger patients since there is some indications that cemented stems
           are less prone to develop osteolysis;
    - useful for patients w/ "stove pipe" type femur, previous fracture, or previous osteotomy since these patients would not be expected to achieve
           a tight fit which is necessary for ingrowth;
    - may be indicated poor bone quality such as RA, osteoporosis, or Paget's disease;
    - Harrington MA, et al, the authors determined that in a stair-climbing test model, the peak proximal cement strains were increased more by changes in
           body wt than they were by changes in neck length. Even during stair-climbing, calcar-collar contact reduced peak cement strains;
           - peak strain magnitudes in proximal cement mantle were increased more by changes in body wt than by changes in length of neck of  stem;
           - strong effect of stem size on the cement strains suggests that cemented femoral stems should not be used in heavy
                  patients with small medullary canals that require a small cemented stem;
           - references
                   - Cemented femoral fixation: a historical footnote. 
                   - Effects of femoral neck length, stem size, and body weight on strains in the proximal cement mantle.
    - outcomes:
           - in the study by Callaghan JJ, et al (2000) the authors followed Charnley Total Hip Arthroplasty
                  patients (with cement) with a minimum 25 year follow up;
                  - of the 327 hips for which the outcome was known after a minimum of 25 years, 295 (90 %) had retained the original implants until
                          the patient died or until the most recent follow-up examination;
                  - of the 62 hips in patients who lived for at least 25 years after the surgery, 48 (77 %) had retained the original prosthesis;
                  - Charnley total hip arthroplasty with cement. Minimum twenty-five-year follow-up.
- Cemented Component Design:
    - prosthesis should have relatively smooth surfaces, w/ no sharp edges, so that sites of stress concentration are eliminated from both prosthesis and cement;
    - a prosthesis that is broader laterally than medially may help to diffuse the compressive stress medially;
    - tapered shape from proximal to distal allows controlled subsidence within the cement column;
    - cobalt-chromium alloy stems are used in most stems, since they generate less particulate debris than titanium implants;
    - triple taper concept: femoral component tapers to a point in both the AP and lateral planes and in addition, the stem is more narrow medially and widens laterally;
    - references:
           - Survivorship analysis of cemented high modulus total hip arthroplasty.
           - Effects of Femoral Neck Length, Stem Size, and Body Weight on Strains in the Proximal Cement Mantle   
           - The design features of cemented femoral hip implants.
           - Analysis of 16 retrieved proximally cemented femoral stems.

- Component Surface:
    - there is controversy about how much bonding should occur between the cement and the femoral stem;
           - excessive bonding between the cement and stem may transfer wt bearing stress to the bone-cement interface, leading to loosening;
           - in contrast, excessive motion between the cement-metal interface, may lead to excessive osteolysis and rapid loosening;
    - definitions:
           - polished: (Ra less than 1 micrometer) polished stems create little abrasion;
           - matte: (Ra less than 2 micrometer) matte finnish will not create excessive abrasion unless stem allows large micomotion;
           - rough: (Ra greater than 2 micrometer) expected to cause excessive abrasion;
    - some are proponents of smooth surface, which may allow subsidence and thereby keeps the cement in compressive loading;
    - many components have a matt finish, which allows some mechanical interlock with the cement;
    - in the study by Howie DW, et al (1998), 4/20 matt coated stems had been revised for aseptic loosening whereas
           0/20 polished stems had been revised (9 year minimum follow up);
    - in the study by Collis and Mohler, the authors evaulated loosening in grit blasted versus polished stems;
           - study included 244 consecutive total hip arthroplasties with a cemented femoral component performed by one surgeon;
           - 4 hips treated with the grit-blasted stem had aseptic loosening with substantial surrounding lysis and required revision; 
           - an additional two hips in this group had radiographic evidence of substantial lysis and were judged to have an impending need for revision;
           - no hip treated with the polished stem required revision, and only one had minimal lysis;
           - this difference regarding failures and impending failures was significant (p = 0.05);
    - references:
           - Loosening of matt and polished cemented femoral stems.   
           - Comparison of Clinical Outcomes in Total Hip Arthroplasty Using Rough and Polished Cemented Stems with Essentially the Same Geometry 
           - The skeletal response to matt and polished cemented femoral stems.
           - Effects of design changes on cemented tapered femoral stem fixation. 
           - Early loosening of the femoral component at the cement-prosthesis interface after total hip replacement.
           - A Rough Surface Finish Adversely Affects the Survivorship of a Cemented Femoral Stem.
           - Long-term results of use of a collared matte-finished femoral component fixed with second-generation cementing techniques. A fifteen-year-median follow-up study.
           - Radiographic Failure Patterns of Polished Cemented Stems.

- Cement Technique:
    - in the report by Shepard MF, et al, the authors performed an experimental study on cement technique;
           - they determined that when using a roughened or precoated cemented femoral component, the surgeon should consider
                   cementing earlier with wetter cement to maximize the cement-prosthesis bond;
           - when implanting a polished femoral component, it is preferable that the cement is doughy, because the cement-prosthesis bond is not influenced
                  by the wetness of the cement and it is easier to maintain the orientation of the femoral component.

    - references:
           - Influence of Cement Technique on the Interface Strength of Femoral Components.  
           - Loosening of the femoral component after use of the medullary-plug cementing technique. Follow-up note with a minimum five-year follow-up.
           - Pressurized cement fixation in total hip arthroplasty.
           - Do we need to vacuum mix or centrifuge cement?
           - Patterns of osteolysis around total hip components inserted with and without cement.
           - The prevalence of femoral osteolysis associated with components inserted with or without cement in total hip replacements. A retrospective matched-pair series.
           - The results of improved cementing techniques for total hip arthroplasty in patients less than fifty years old. A ten-year follow-up study.
           - Radiolucency at the bone-cement interface in total knee replacement. The effects of bone-surface preparation and cement technique.
           - The femoral component in total hip arthroplasty. Six to eight-year follow-up of one hundred consecutive patients after use of a third-generation cementing technique.
           - Total hip arthroplasty with use of so-called second-generation cementing techniques. A fifteen-year-average follow-up study.

- Cement Mantle:
    - current recommendations are to have at least 2 mm of a uniform cement mantle around the femoral component;
    - in the study by Joshi RP, et al (1999), the authors found that a 3 mm cement mantle around the femoral component, and a
           6 mm mantle around the acetabular component were associated with the lowest incidence of osteotlysis;
    - references:
           - Changes in the calcar femoris in relation to cement technology in total hip replacement.   
           - The cement mantle in total hip arthroplasty. Analysis of long-term radiographic results.
           - Osteolysis after Charnely primary low friction arthroplasty.  A comparison of two matched paired groups.   
           - Should the cement mantle around the femoral component be thick or thin?
           - Cement microcracks in thin-mantle regions after in vitro fatigue loading.
           - Importance of a thin cement mantle. Autopsy studies of eight hips.

- Grading of Cement Technique: (Barrack, et al. (1992) and Mulroy, et al. (1995))
    - grade A: meduallary canal completely filled w/ cement (white out).
    - grade B: a slight radiolucency exists at the bone cement interface.
    - grade C: a radiolucency of more than 50% at the bone cement interface.
    - grade D: a radiolucency involving more than 100% of the interface between bone and cement in any projection, including absence of cement distal to the stem tip;
    - note: this grading system has been criticized since it is somewhat influenced by the amount of cancellous bone removed during reaming and broaching;
            - when the entire cancellous bed is removed, there will often be "white out" (indicating good cementing technique), and yet
                    there will be no cancellous foothold for the cement;
    - cement mantle:
            - as noted by Mulroy, et al. (1995), a femoral cement mantle less than 1 mm and defects in the cement mantle are associated with early loosening;
            - Jasty, et al (1990), noted that cement voids and stem abutment against the femur (indicating an inadequate cement mantel) were associated w/ loosening;
            - similarly, Maloney, et al (1990), note that circumferential cement mantles with component centralization prevents loosening;
            - references: 
                   - Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review.
                   - Total hip arthroplasty with use of so-called second-generation cementing techniques. A fifteen-year-average follow-up study.
                   - Histomorphological studies of the long-term skeletal responses to well fixed cemented femoral components.
                   - Bone lysis in well fixed cemented femoral components.   
                   - Radiographic comparison of cementing techniques in total hip arthroplasty.


- Cement Disease:
    - references:
           - Cement disease.
           - Cardiac arrest during hip arthroplasty with a cemented long-stem component. A report of seven cases.
           - Bone lysis in well-fixed cemented femoral components

- Charnely:

- Charnely-Muller:

Total hip replacement with cemented, uncemented, and hybrid prostheses. A comparison of clinical and radiographic results at two to four years.

Comparison of a hybrid with an uncemented total hip replacement. A retrospective matched-pair study.

Hybrid total hip arthroplasty.

Hybrid total hip replacement. A 6.5-year follow-up study.

Charnley total hip arthroplasty with cement. Fifteen-year results.

Histomorphological studies of the long-term skeletal responses to well fixed cemented femoral components.

Long-term results of cemented total hip arthroplasty.

Charnley total hip arthroplasty. A ten- to 14-year follow-up study.

Long-term follow-up of cemented total hip arthroplasty in rheumatoid arthritis.

The survival of the cemented femoral component of a total hip replacement.

Late onset femoral stress fracture associated with extruded cement following hip arthroplasty. A case report.

Incidence of heterotopic ossification after total hip replacement: effect of the type of fixation of the femoral component.

Total hip arthroplasty with cement. A long-term radiographic analysis in patients who are older than fifty and younger than fifty years.

Cemented total hip arthroplasty with contemporary techniques. A five-year minimum follow-up study.

The effect of improved cementing techniques on component loosening in total hip replacement. An 11-year radiographic review.

Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review.

The femoral component in low-friction arthroplasty after ten years.

The Clayton total hip arthroplasty. A ten-year follow-up study.

Charnley low-friction arthroplasty in the young patient.

Cemented versus cementless total hip arthroplasty. A comparative study of equivalent patient populations.

A 12- to 18-year radiographic follow-up study of Charnley low-friction arthroplasty. The role of the center of rotation.

Long-term results of cemented femoral revision surgery using second- generation techniques. An average 11.7-year follow-up evaluation.

Total hip arthroplasty with the Charnley prosthesis in patients fifty-five years old and less. Fifteen to twenty-one-year results.

Total hip arthroplasty with cement after renal transplantation. Long-term results.