Current attitudes to cementing techniques in British hip surgery

Abstract

Aseptic loosening is the major problem in hip joint replacement. Improved cementing techniques have been shown to improve the long-term survival of implants significantly. To assess the use of modern cementing techniques in British surgeons, a detailed questionnaire was sent to all Fellows of The British Orthopaedic Association (BOA) regarding cement preparation, bone preparation, cementing technique and prostheses used in total hip arthroplasty. Excluding retired fellows, surgeons who use no cement, and those who had filled in forms inadequately, 668 responded, who between them performed 43,680 hip arthroplasties per year. In this survey, 21 different types of hip prostheses were implanted by the surgeons; 48% of hips implanted were Charnley type. Of the surgeons, 46% used Palacos with gentamicin as their cement for both the femur and acetabulum. For the femur, 44% of surgeons remove all cancellous bone, 40% use pulse lavage, 59% use a brush to clear debris, 94% dry the femur, 97% plug the femur, 76% use a cement gun and 70% pressurise the cement. For the acetabulum, 88% of surgeons retain the subchondral bone, 40% use pulse lavage, 100% dry the acetabulum, 22% use hypotensive anaesthesia and 58% pressurise the cement. Overall only 25% of surgeons (26% of hips implanted) use 'modern' cementing techniques. This has implications for the number of arthroplasties that may require early revision.

Full text

Ann
R
Coll
Surg
Engl
1994;
76:
396-400
Current
attitudes
to
cementing
techniques
in
British
hip
surgery
Aresh
Hashemi-Nejad
FRCS
Orthopaedic
Senior
Registrar
Nicholas
J
Goddard
FRCS
Orthopaedic
Consultant
Nicholas
C
Birch
FRCS
Orthopaedic
Senior
Registrar
Orthopaedic
Department,
The
Royal
Free
Hospital
NHS
Trust,
London
Key
words:
Hip
surgery;
Cementing
technique;
Prostheses
Aseptic
loosening
is
the
major
problem
in
hip
joint
replacement.
Improved
cementing
techniques
have
been
shown
to
improve
the
long-term
survival
of
implants
significantly.
To
assess
the
use
of
modern
cementing
techniques
in
British
surgeons,
a
detailed
questionnaire
was
sent
to
all
Fellows
of
The
British
Orthopaedic
Association
(BOA)
regarding
cement
preparation,
bone
preparation,
cementing
technique
and
prostheses
used
in
total
hip
arthroplasty.
Excluding
retired
fellows,
surgeons
who
use
no
cement,
and
those
who
had
filled
in
forms
inadequately,
668
responded,
who
between
them
performed
43
680
hip
arthroplasties
per
year.
In
this
survey,
21
different
types
of
hip
prostheses
were
implanted
by
the
surgeons;
48%
of
hips
implanted
were
Charnley
type.
Of
the
surgeons,
46%
used
Palacos
with
gentamicin
as
their
cement
for
both
the
femur
and
acetabulum.
For
the
femur,
44%
of
surgeons
remove
all
cancellous
bone,
40%
use
pulse
lavage,
59%
use
a
brush
to
clear
debris,
94%
dry
the
femur,
97%
plug
the
femur,
76%
use
a
cement
gun
and
70%
pressurise
the
cement.
For
the
acetabulum,
88%
of
surgeons
retain
the
subchondral
bone,
40%
use
pulse
lavage,
100%
dry
the
acetabulum,
22%
use
hypotensive
anaesthesia
and
58%
pressurise
the
cement.
Overall
only
25%
of
surgeons
(26%
of
hips
im-
planted)
use
'modern'
cementing
techniques.
This
has
implications
for
the
number
of
arthroplasties
that
may
require
early
revision.
Total
hip
arthroplasty
(THA)
is
one
of
the
most
successful
and
cost-effective
operations
ever
introduced,
and
annually
800
000
THAs
are
done
worldwide.
Aseptic
loosening
of
the
components
is
the
most
common
long-
term
complication
and
constitutes
80%
of
the
revisions
(1).
Using
cementing
techniques
initially
advocated
by
Charnley
(first
generation)
the
incidence
of
radiographic
loosening
of
the
femoral
component
was
reported
to
be
30%
to
40%
at
10
years
(2,3).
Using
improved
cementing
techniques
with
intramedullary
bone
plugs,
cement
gun
and
pressurisation
(second
generation),
the
incidence
of
radiographically
loose
femoral
components
fell
to
3%
at
11
years
(4).
Comparison
of
patients
undergoing
THAs
using
only
a
cement
gun
with
improved
cementing
techniques
in
a
single
centre
showed
a
reduction
of
radiological
loosening
from
21%
at
a
mean
of
4
years
in
the
first
group
to
no
loosening
in
the
group
having
the
improved
cementing
technique
(5).
De
Lee
and
Charnley
(6)
reported
a
9%
cup
migration
rate
which
was
associated
with
a
thin
acetabular
wall.
Fowler
et
al.
(7)
using
a
technique
that
pressurised
cement
on
to
clean
cancellous
bone
demonstrated
signifi-
cant
reduction
in
cup
migration
at
7
and
13
year
reviews.
Mulroy
and
Harris
(4)
showed
no
change
in
the
incidence
of
radiographically
loose
acetabulum
using
their
improved
cementing
techniques.
We
undertook
a
study
to
review
the
current
attitudes
to
cementing
technique
in
British
hip
surgery.
Method
To
assess
the
cementing
practice
of
British
Orthopaedic
Surgeons
for
primary
hip replacement,
we
posted
a
questionnaire
(Fig.
1)
to
all
1084
Fellows
of
The
British
Orthopaedic
Association.
The
questionnaire
was
in
four
Correspondence
to:
Aresh
Hashemi-Nejad
FRCS,
Orthopaedic
Departnent,
The
Royal
Free
Hospital
NHS
Trust,
Pond
Street,
London
NW3
2QG

FEMORAL
CEMENTING
TECHNIQUES
1.
Do
you
attempt
to
remove
as
much
cancellous
bone
as
possible?
2.
Do
you
use
pulsed
lavage?
3.
Do
you
use
an
intra-medullary
brush
to
clear
bone
debris?
4.
Do
you
dry the
femoral
shaft
prior
to
cementing?
If
'yes'
please
ring
or
specify
your
usual
technique
-Plug
-Swab
-Swab
+
adrenaline
-Other?
5.
Do
you
plug
the
distal
femur?
If
'yes'
please
ring
or
specify
your
usual
technique
-Cancellous
bone
plug
-Cement
-HDP
(eg.
Hardinge,
JRI)
-Other
6.
Do
you
use
a
cement
gun?
7.
Do
you
pressurize
the
cement
prior
to
insertion
of
the
prosthesis?
8.
What
is
your
usual
femoral
component?
Please
specify:
9.
What
head
size
do
you
generally
use?
Please
ring
or
specify
-22.25
mm
-25
mm
-28
mm
-29
mm
-32
mm
-Other
Approximately
how
many
cemented
replacements
are
done
in
your
name
per
annum?
ACETABULAR
CEMENTING
TECHNIQUES
1.
Do
you
aim
to
retain
the
subchondral
bone?
2.
Do
you
use
anchor
holes?
-"Classical"
large
ilial,
ischial
+pubic
-Multiple
small
anchor
holes
-Other
3.
Do
you
use
pulsed
lavage?
4.
Do
you
dry
the
acetabulum
prior
to
cementing?
Please
ring
or
specify
your
technique:
-Swab
-Swab
+
adrenaline
-Other
5.
Do
you
use
controlled
hypotension
prior
to
cementing?
6.
Do
you
pressurize
the
cement
prior
to
insertion
of
the
socket?
CEMENT
PREPARATION
1.
Which
cement
do
you
usually
use
for:
The
femur?
-0MW
-Simplex
-Palacos
-Palacos
+
Gentamicin
-Other?
2.
Do
you
use
low
viscosity
cement?
-Acetabulum
-Femur
3.
Do
you
chill
the
monomer?
4.
Do
you
centrifuge
the
cement
prior
to
insertion?
5.
Do
you
vacuum
mix
the
cement?
(Not
simple
fume
extraction)
The
acetabulum?
-0MW
-Simplex
-Palacos
-Palacos
+
Gentamicin
-Other?
Figure
1.
Questionnaire.
parts
regarding:
(1)
The
prosthesis
used;
(2)
The
cement
and
its
preparation,
(3)
Femoral
canal
preparation
and
cementing
technique
and
(4)
Acetabular
preparation
and
cementing
technique.
Results
A
total
of
719
surgeons
responded
to
the
survey.
Excluding
retired
fellows,
surgeons
who
use
no
cement,
and
those
who
had
filled
in
forms
inadequately,
668
responded,
who
between
them
performed
43
680
hip
arthroplasties
per
year
(an
average
of
65
hips
per
surgeon
per
year
(range
10-250)).
Excluding
retired
fellows
and
those
who
do
no
hips
from
the
non-
responding
group,
the
survey
is
representative
of
70%
of
all
BOA
Fellows
performing
hip
arthroplasty.
The
results
of
the
questionnaire
were
analysed
with
respect
to
the
number
of
surgeons
performing
the
technique
and
number
of
hips
which
underwent
a
particular
practice.
Cementing
techniques
in
hip
surgery
397
y
y
y
y
N
N
N
N
Y
N
Y
N
Y
N
y
y
y
y
N
N
N
N
Y
N
Y
N
y
Y
N
N
N
N
N
N
N
N
y
y
y
y
y
y

398
A
Hashemi-Nejad
et
al.
50-
40-
0
120
V_-RZ--
O
__
Charnasy
H
Muller.
Furlog
Exeter
moirotm
1
Type
of
Prosthesis
Figure
2.
Prostheses
used.
...............
%
of
Hips
50-
40-
..........I.....
...
C30
.
.0-
2
I
10-
0-
-
.-
-
s _
-
................................
_~~~~~~~~~~~~~~~~~~~I
CMW
SImplex
Palace
Pa
&
Gent
Other
Typ
of
Cement
Figure
4.
Femoral
cement
used.
_9
0
_
22.25
25
26
28
Head
Sizes
(mm)
32
Figure
3.
Head
sizes
used.
*
%
o
Surgeons
*
%od
Hips
CMW
Simplex
Piaco.
PalaeoJ
&Gent
Other
Type
of
Cement
Figure
5.
Acetabular
cement
used.
E_i
......
web
&
S
W
s"
a
PI
Drying
Technlqui
e
.
of
Surgeons
*
%
of
Hips
60
50-
......................
.
....
=40-
..................
130
.......................
---20--F%1
mm~~~~
0
OUw
Figure
6.
Femoral
drying
technique.
C
llWll
HDP
Type
Of
Plug
Figure
7.
Femoral
distal
plug.
Prostheses
used
There
were
21
different
types
of
hip
being
used
by
the
surgeons.
Charnley
types
were
used
by
50%
of
surgeons
and
accounted
for
48%
of
hips
implanted
(Fig.
2).
Of
the
surgeons,
4%
used
more
than
one
type
of
hip.
Of
hips
implanted,
49%
had
22.25
mm
heads
and
28%
had
28
mm
heads
(Fig.
3).
Cement
preparation
Of
the
surgeons,
6%
chilled
the
monomer,
11%
vacuum
mixed
and
2%
centrifuged
the
cement.
In
the
femur,
26%
of
surgeons
used
low-viscosity
cement
and
in
the
acetabulum
7%.
Palacos
with
gentamicin
was
used
by
49
%
of
surgeons
in
the
femur
and
by
45%
in
the
acetabulum
(Fig.
4
and
Fig.
5).
Femoral
technique
Of
the
surgeons,
44%
aim
to
remove
the
cancellous
bone,
40%
use
pulse
lavage,
and
59%
use
a
brush
to
clear
the
debris;
94%
of
surgeons
dry
the
femur
(Fig.
6),
most
commonly
using
a
swab;
97%
plug
the
distal
femur
(Fig.
7),
most
commonly
using
a
high
density
polyethylene
implant;
76%
use
a
cement
gun
and
70%
pressurise
the
cement.
Acetabular
technique
The
subchondral
bone
was
retained
by
88%
of
surgeons
(in
82%
of
hips
implanted).
All
surgeons
use
anchor
holes
(Fig.
8)
and
all
dry
the
acetabulum
(Fig.
9);
40%
of
sur-
geons
use
pulse
lavage
and
23%
use
hypotensive
anaes-
thesia;
58%
pressurise
the
cement
in
the
acetabulum.
'%'ofSurgons
*
%of
Hips
50
*
%
of
Surgeon
*
%
of
Hips
5
0
...
................
4
0
........................
-30
e
_
21
12
0
1-.
10i
0-
60
50
..
40-
..
40
WS
230.-
20
..
10
-
0
a
%
d
Surgeons
*
%o1Hips
l
40
E30
-.
Ara
I

Cementing
techniques
in
hip
surgery
399
50
--
g
l
%of
Surgeons
*
%of
Hips
40-
o.
Classical
Multiple
Other
Type
of
Anchor
Hole
Figure
8.
Acetabular
anchor
holes.
Discussion
There
is
no
great
variation
in
the
numbers
of
hips
implanted
in
a
particular
way
and
the
numbers
of
surgeons
performing
the
different
techniques.
The
number
of
THAs
performed
per
surgeon
per
year
reported
in
this
study
seems
a
little
high,
and
although
the
numbers
reported
may
have
been
exaggerated
we
feel
the
techniques
reported
are
not.
There
is
a
wide
range
of
hip
prostheses
available
to
the
surgeon,
many
of
which
have
no
long-term
outcome
studies.
There
are
21
types
of
hip
imnplanted
by
the
surgeons
in
this
study,
86%
of
the
hips
implanted
are
Charnley,
Howse,
Muiller,
Furlong,
Exeter
and
Stanmore
types.
The
wide
variation
of
prosthesis
used
has
been
reported
previously
(8),
but
not
the
frequency
with
which
they
are
used.
Of
the
surgeons,
50%
implant
Charnley
type
hips,
which
account
for
48%
of
hips
implanted;
7%
of
surgeons
implant
Exeter
type
hips
which
account
for
9%
of
hips
implanted;
4%
of
surgeons
use
more
than
one
type
of
hip
as
their
choice
of
implant.
In
the
absence
of
long-term
comparative
prospective
trials
it
is
difficult
to
know
if
one
prosthesis
is
better
than
the
other.
The
biological
consequences
of
particulate
wear
debris
are
a
cause
for
concern.
Livermore
et
al.
(9)
showed
that
the
greatest
amount
and
linear
wear
occurred
with
a
22.25
mm
head,
the
greatest
amount
and
volumetric
wear
was
seen
in
the
32
mm
head
and
the
least
amount
and
linear
wear
were
associated
with
the
use
of
a
28
mm
head
diameter,
suggesting
the
best
wear
characteristics
are
realised
with
a
mid-range
head
size.
Morrey
and
Ilstrup
(10)
demonstrated
a
higher
incidence
of
acetabular
loosening
with
the
32
mm
head
size
compared
with
the
22.25
mm
component,
which
has
a
smaller
frictional
torque
force.
This
survey
showed
that
50%
of
hips
implanted
are
with
a
22.25
mm
head.
This
is
a
reflection
of
the
high
number
of
Chamley
types
implanted.
Only
25%
of
surgeons
(28%
of
hips)
implanted
28
mm
heads.
The
Wrightington
group
and
others
still
use
Gharnley's
original
cementing
technique
and
have
indeed
reported
moer
ceenin
tehiqe
(3.
Ths
moEr
(third
geeain
tehiqe
inlud
th
usIfameu_r
0s
.....*...o....u.r.
......
*
%of
Hips
._
_.
0
2
40
--
_
_ ,
.......
...
....
..
.....
....
.
.......
...
.........
.....
20
Swaob
SWab
&
Adenafin.
Swab
&
PmxI
OUwr
Drying
Technique
Figure
9.
Acetabular
drying
technique.
plug,
use
of
a
cement
gun,
cleaning
of
the
intertrabecular
spaces
(using
a
brush
and
pulse
lavage),
pressurisation
and
reduction
of
the
porosity
of
the
cement
(14).
For
the
acetabulum,
pressurisation
of
cement
on
to
clean
cancellous
bone
demonstrated
significant
reduction
in
cup
migration
(7).
Excluding
the
centrifugation
of
cement,
which
is
only
performed
by
2%
of
the
surgeons
in
this
survey,
only
25%
of
surgeons
(26%
of
hips
implanted)
perform
these
modem
'third
generation'
cementing
techniques.
We
did
note
that
surgeons
who
implanted
20
or
less
hips
per
year
had
different
cementing
practice
to
those
who
implanted
more.
Only
six
out
of
105
surgeons
in
this
group
undertook
modem
cementing
techniques.
This
has
implications
on
the
potential
number
of
early
failures
due
to
aseptic
loosening.
We
feel
the
emphasis
in
hip
surgery
should
move
from
implanting
new
designs
to
improving
the
cementing
techniques
on
tried
and
tested
prostheses.
References
1
Malchau
H,
Herberts
P,
Ahnfelt
LE,
Johnell
0.
Prognosis
of
total
hip
replacement.
Results
from
the
national
register
of
revised
failures
1979-1990
in
Sweden-a
ten
year
follow-up
study
of
92
675
THR.
Scientific
Exhibition
presented
at
the
61st
American
Academy
of
Orthopaedic
Surgeons,
1993.
2
Stauffer
RN.
Ten
year
follow
up
study
of
total
hip
replacement
with
particular
reference
to
roentgenographic
loosening
of
the
components.
J
Bone
joint
Surg
1982;
64A:
983-90.
3
Sutherland
CJ,
Wilde
AH,
Borden
LS,
Marks
KE.
A
ten
year
follow
up
of
one
hundred
consecutive
Muiller
curve
stem
total
hip
replacement
arthroplasties.
J
Bone
joint
Surg
1982;
64A:
970-82.
4
Mulroy
RD,
Harris
WH.
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