Injury, Int. J. Care Injured 32 (2001) 461–464

Current cementing techniques in hip hemi-arthroplasty

S. Scott a,*, A.W. McCaskie b, S.J. Calder c, C. Wildin d, P.J. Gregg b

a Newcastle General, Newcastle upon Tyne, UKb Freeman Road Hospital, Newcastle upon Tyne, UK

c Leeds General Infirmary, Leeds, UKd Glenfield General Hospital, Leicester, UK

Received 5 September 2000; received in revised form 29 November 2000; accepted 5 December 2000

Abstract

To assess the use of modern cementing techniques in hip hemi-arthroplasty a postal questionnaire was sent during 1998 to allBritish Orthopaedic Training Association (B.O.T.A.) members regarding use of cement, type of cement, bone preparation andcementing technique. The results of this survey were compared to a similar survey in 1994 to assess any change in practice. Twohundred and eighty-six trainees responded to the 1998 survey, 352 to the 1994 survey. The use of uncemented prostheses haddecreased from 31.3 in 1994 to 21.7% in 1998. Normal viscosity Palacos cement remains the most common cement in use, 64.3%in 1998. The use of antibiotic loaded cement has increased from 53.7 in 1994 to 67.9% in 1998. For bone preparation 47.3% oftrainees in 1998 used a modern technique (syringe irrigation/pulsed lavage, brushing, gauze packing) compared to 35.1% in 1994.Modern cement insertion (retrograde gun, cement restriction and sustained pressure) was carried out by 39.3% in 1998 comparedto 28.5% in 1994. Overall 27.2% of trainees used modern cementing techniques in hip hemi-arthroplasty, compared to 19.4% in1994. Modern cementing techniques are used by a minority of British orthopaedic trainees, but in comparison to 1994 their usehas increased. © 2001 Elsevier Science Ltd. All rights reserved.

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1. Introduction

Femoral neck fracture is a common injury in theelderly with a reported annual incidence as high as86/100 000 population [1], and an average patient age of79. Intracapsular fracture accounts for approximately51% of this figure [2]. Cemented hemi-arthroplasty of-fers a successful form of treatment for the majority ofpatients with intracapsular fractures, with greater mo-bility, less residual pain and a lower revision rate thanuncemented hemi-arthroplasty [3–5]. Cemented hemi-arthroplasty is however associated with an increasedincidence of intraoperative and postoperative car-diopulmonary complications [6–8].

Modern cementing techniques in primary total hipreplacement have been shown to reduce the incidence ofloosening of the prosthesis [9,10] and to reduce theextent of embolic showers during cement and prosthesisinsertion and to reduce the incidence of cardiopul-

monary compromise [11,12]. It could therefore be hy-pothesized that modern cementing may be beneficial inhip hemi-arthroplasty to reduce cardiopulmonary com-plications, over and above any effect on loosening.

A number of studies have examined the currentcementing techniques among orthopaedic surgeons car-rying out primary total hip replacement [13,14], but nodata is currently available regarding cementing tech-niques in hemi-arthroplasty.

The aim of this study was to quantify the use ofmodern cementing techniques in hip hemi-arthroplastyamong UK orthopaedic surgical trainees and to assessany change in practice with that of 4 years previously.

2. Methods

During 1994 and 1998 a questionnaire (Fig. 1) wasposted to all members of the British Orthopaedic Train-ing Association (B.O.T.A.). The questionnaire was insix parts regarding:1. cemented or uncemented hemi-arthroplasty;2. type of cement;

* Corresponding author. Present address: 4, Low Meadows, Clea-don Village, Sunderland, Tyne & Wear, SR6 7QJ, UK. Tel.: +44-191-5368311.

0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved.PII: S 0 0 2 0 -1383 (00 )00252 -7

S. Scott et al. / Injury, Int. J. Care Injured 32 (2001) 461–464462

3. use of antibiotic loaded cement;4. femur preparation;5. cementing technique;6. similarity to technique for total hip replacement.

3. Results

Three hundred and fifty-two trainees responded tothe 1994 survey and 286 to the 1998 survey. Thisrepresents 70 and 61% of all B.O.T.A members. Theresults of the survey are shown in Table 1.

Bone cement was used at least sometimes by 224(78.3%) trainees replying to the survey in 1998 com-pared to 242 (68.7%) during 1994. Conversely 62(27.1% of trainees never used cement in 1998 comparedto 110 (31.3%) in 1994. Normal viscosity cement was

Table 1Results of completed questionnaire

1998 (%) 1994 (%)

Bone cementYes 40.936.4

21.7 31.3No27.8Sometimes 41.9

Cement �iscosity82.6Normal 81.0

2.91.3Reduced10.7Low 8.7

Cement brandPalacos 64.3 62.5

15.2CMW 23.1Simplex 8.36.7

Antibiotic cementYes 53.767.9

26.7No 33.18.0 11.6Sometimes

Bone preparationReaming 91.5 85.1Syringe irrigation 65.2 73.1

23.135.7Pulse lavagePower brush 3.7 4.1

37.5Man. brush 39.785.3 72.3Gauze pack

14.98.0Haemostatic agent0.1Other 0.1

Cement insertionFinger pack 39.329.0Retrograde gun 54.170.1Syringe 12.813.4

67.873.2Cement restrictor45.9Vent tube 46.0

44.6Sustained pres 31.48.5 6.6Half moon collar

Same technique as THR53.3Yes 48.746.751.3No

Fig. 1. Illustration of blank questionnaire.

used by the majority of trainees with no differencebetween the two surveys, likewise Palacos cement re-mained the most common cement brand, 144 (64.3%) in1998 compared to 151 (62.5%) in 1994. The use ofantibiotic loaded cement appears to have increased,with 152 (67.9%) trainees using it preferentially in the1998 survey compared to 130 (53.7%) during 1994.

During bone preparation the use of pulsed lavage hasincreased from 56 (23.1%) in 1994 to 79 (35.7%) in1998, as had the use of gauze packing, with an increasefrom 175 (72.3%) in 1994 to 191(85.3%) in 1998. Theuse of haemostatic agents fell from 36 (14.9%) in 1994to 18 (8.0%) in 1998. Little change in practice wasfound for the use of reaming, syringe irrigation andmanual or power brushing. During cement insertionlarge increases in use were found for both retrogradegun, 131 (54.1%) in 1994 to 157 (70.1%) in 1998, and

S. Scott et al. / Injury, Int. J. Care Injured 32 (2001) 461–464 463

sustained pressure with a rise from 76 (31.4%) in 1994to 100 (44.6%) in 1998. The use of finger packing fellfrom 95 (39.3%) in 1994 to 65 (29.0%) in 1998. The useof cement restriction, vent tube and half moon collarremained largely unchanged between surveys.

The results were analysed to determine the number oftrainees who used a modern cementing technique (Fig.2). The criteria for this were:1. Modern femoral preparation: syringe irrigation or

pulse lavage and manual or power brushing andgauze packing or drying.

2. Modern cement insertion: retrograde cement gunand cement restrictor or bone block and sustainedpressure.

Those trainees who fulfilled both criteria were re-garded as using a modern cementing technique. Eighty-five trainees (35.1%) were found to fulfil the criteria forfemoral preparation in 1994 compared to 106 (47.3%)in 1998. Sixty-nine trainees (28.5%) practised moderncement insertion in 1994 compared to 88 (39.3%) in

1998. Overall 47 (19.4%) trainees used a modern ce-menting technique for hemi-arthroplasty in 1994 com-pared to 61 (27.2%) in 1998.

Little difference was found in the number of traineeswho used the same technique for primary total hipreplacement as hemi-arthroplasty, 129 (53.3%) in 1994compared to 109 (48.7%) in 1998.

4. Discussion

The insertion of cement and implant during hiphemi-arthroplasty for femoral neck fracture has a docu-mented incidence of morbidity and mortality as a resultof cardio-pulmonary compromise. A number of mecha-nisms are thought to be responsible for this phe-nomenon including emboli of fat and debris from thefemoral canal during cement and implant insertion[15–18].

Experimental studies using transoesophagealechocardiography have shown embolic showers duringcement pressurisation [19,20]. Changes in measured pul-monary parameters show a direct correlation to theextent of the embolic shower [21]. Thorough lavage andbrushing of the femoral canal prior to cement insertionhas been shown to reduce the embolic response andreduce the disturbance in pulmonary function as mea-sured by endtidal carbon dioxide concentrations andoxygen saturation [12,22].

Cement restriction and a retrograde gun techniquefor cement insertion have been shown to be associatedwith less physiological disturbance, despite attaininghigher intramedullary pressures in the femoral canal[11]. The mechanism for this observation is unclear.Cement restriction may help compartmentalise marrowfat, blood, and debris. Use of a retrograde cement gunresults in more even pressure distribution and lesspressurisation of residual debris against the cementrestrictor than finger packing. A vent tube might fur-ther reduce distal trapping of debris. The use of sus-tained pressure appears to have no detrimental effecton physiological paramenters, as maximum pressure isgenerated not during cement insertion but on implantinsertion.

A modern cementing technique which incorporatescanal lavage, brushing and drying with retrograde guninsertion, cement restriction and sustained pressure willnot only produce better cement fixation but may alsooffer a safer method of cement insertion as a result ofless cardiopulmonary compromise.

The number of trainees currently adopting a moderncementing technique for hemi-arthroplasty surgery wasfound to be 27.2%. This compares to 19.4% in 1994 andto 25% of consultant orthopaedic surgeons performingprimary total hip replacements [13].

Fig. 2. Block chart of percentage of trainees using modern cementingtechniques.

S. Scott et al. / Injury, Int. J. Care Injured 32 (2001) 461–464464

It is interesting to note that of those trainees whostated that they performed primary total hip replace-ment in the same manner as hemi-arthroplasty 42%used a modern cementing technique. Does this suggesta more wide spread adoption of modern cementingtechniques for primary total hip replacement amongtrainees than among consultants?

5. Conclusion

It would appear that despite evidence to suggest thatmodern cementing techniques may improve fixationand reduce cardiopulmonary complications in hemi-arthroplasty, there has not yet been wide spread adop-tion of its use, although comparison of the currentversus 1994 data would suggest that its use is on theincrease. This may reflect the more recent research onthis subject. [11–14,20,21].

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