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Cemented Femoral Revision
The Journal of Arthroplasty Vol. 20 No. 4 Suppl. 2 2005
Cemented Femoral Revision Lest We Forget Jay R. Lieberman, MD
Abstract: Cemented femoral revisions can provide durable fixation when used for specific indications. These indications include elderly patients with minimal bone loss or large femoral canals and the cement-within-cement technique where a new femoral component is cemented into an intact cement mantle. Key words: cement femoral revision, cement-within-cement technique, intact cement mantle. n 2005 Elsevier Inc. All rights reserved.
The investigators concluded that the results with cemented stems were technique-dependent, and they recommended the use of long stems. Haydon et al [9] recently reported on the results of 97 cemented femoral revision stems that had been followed for a minimum of 10 years. The 10-year survival rate was 91% with aseptic loosening as an end point and 71% with mechanical failure rate as an end point. The mechanical failure rate was defined as the sum of probable radiographic loosening, definite radiographic loosening, and the stems actually revised. Poor bone stock was associated with increased failure. Hips with a category A or B cement mantle showed improved mechanical survival, and third-generation cementing techniques (vacuum centrifugation of cement and distal and proximal centralizers) were associated with a significant improvement in the 10-year survival rate compared with second-generation techniques. In addition, first-generation techniques (hand packing of cement) were associated with decreased survival compared with secondgeneration techniques. The data from the Swedish registry and the study of Haydon et al show that cemented femoral revision can be successful with appropriate patient selection and good surgical technique that results in satisfactory fixation between the cement and bone. The purpose of this review is to highlight the indications for cemented revisions and to provide technical tips that can facilitate a successful cemented revision.
Cementless fixation is the preferred option for most revision femoral components. However, there are specific indications for the use of cemented stems in revision cases. The results of cemented femoral revisions reported in the 1980s were quite poor [1-3]. The loosening rates in these studies were all greater than 12% with a maximum average followup of only 4.5 years. More recent results with midterm follow-up using modern cementing techniques show improved results [4-7]. Although these results were still not equivalent to those reported for cementless fixation, they suggested that there is a role for the use of cemented revision femoral components. Recently, Malchau et al [8] reported the results of the Swedish Registry from 1979 to 2000. The registry reported on 16 577 revision femoral components using cement alone or the impaction grafting technique. The 10-year survival rate for cemented stems was 78%. There was a 3.3 times increased risk of re-revision when the first revision occurred within 5 years of the primary total hip arthroplasty. Men had a 13% increased risk of stem loosening.
From the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California. No benefits or funds were received in support of the study. Reprint requests: Jay R. Lieberman, MD, Department of Orthopaedic Surgery at UCLA, Los Angeles, CA 90095. n 2005 Elsevier Inc. All rights reserved. 0883-5403/05/2004-2021$30.00/0 doi:10.1016/j.arth.2005.03.005
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Cemented Femoral Revision ! Jay R. Lieberman
Indications The indications for cemented femoral revisions include (1) elderly patients with minimal bone loss or large femoral canals, (2) the cement-withincement technique where a new femoral component is cemented into an intact cement mantle, (3) proximal femoral replacements which are generally reserved for elderly patients with extensive bone loss, and (4) single or 2-stage reimplantation to deliver antibiotics. We will focus on the first 2 indications in this review. The best results with cemented femoral revisions are associated with minimal loss of metaphyseal bone and an intact diaphysis. In elderly lowdemand patients, it is also appropriate to consider using a cemented stem when there is some metaphyseal bone loss and a completely intact diaphysis. This will allow for good cement fixation in the diaphysis. However, extensively porous coated devices will probably provide more reliable results when treating patients with moderate or extensive metaphyseal bone loss. There are a number of technical tips that can enhance results when performing a cemented femoral revision. First, remove the neocortex that forms when a cemented stem loosens [10]. Second, use a long-stem prosthesis that extends 2 to 3 diameters beyond the distal tip of the prior stem [8,11]. Third, use a cement restrictor to enhance cement fixation. Fourth, use antibiotics in the cement (3.6 g in 2 packs of cement). The neocortex must be removed or it will not be possible to obtain adequate interdigitation between the cement and the bone. Recent data have also shown enhanced results when cementing longer stems in place [8,11]. The use of a cement restrictor will enhance pressurization of the cement which is necessary to obtain a durable construct. The cement-within-cement technique for revision of the femoral component can be useful in specific situations [12]. Laboratory studies have shown little loss of sheer strength when applying fresh cement to old cement [13]. The concept is to cement the new femoral stem into a stable cement mantle. Lieberman et al reported on 19 total hip arthroplasties that were revised using this technique. At an average follow-up of 59 months, 18 of 19 patients had a good or excellent result. A prerequisite for this technique is a stable cement mantle. This technique is quite useful in a number of situations including (1) enhancing exposure when performing an acetabular revision, (2) revision of a nonmodular femoral component at
73
the time of acetabular revision to improve offset and stability, and (3) revision of a malaligned femoral component to improve the version of the femoral component. There are a few technical tips that can enhance the results when using this technique. First, select a thinner femoral prosthesis than the previous stem to obtain an adequate mantle of new cement. This new stem needs to have appropriate offset to ensure stability. Second, prepare the femoral canal with either a burr or an ultrasound device [12,14]. This will allow for a larger cement mantle and will increase the surface area between the old and new cement. Third, place the new cement into the femoral canal in the liquid phase to promote integration between the new and old cement. Fourth, use antibiotics in the cement (3.6 g in 2 packs of cement). In summary, cemented femoral stems can be used successfully in elderly patients with minimal bone loss or when using the cement-within-cement technique when there is an intact cement mantle.
References 1. Amstutz HC, Ma SM, Jinnah RH, et al. Revision of aseptic loose total hip arthroplasties. Clin Orthop 1982;170:21. 2. Pellicci PM, Wilson Jr PD, Sledge CB, et al. Long-term results of revision total hip replacement. A follow-up report. J Bone Joint Surg Am 1985;67:513. 3. Kavanagh BF, Ilstrup DM, Fitzgerald Jr RH. Revision total hip arthroplasty. J Bone Joint Surg Am 1985;67:517. 4. Engelbrecht DJ, Weber FA, Sweet MB, et al. Longterm results of revision total hip arthroplasty. J Bone Joint Surg Br 1990;72:41. 5. Stromberg CH, Herberts P. A multicenter 10 year study of cemented revision total hip arthroplasty in patients younger than 55 years old. A follow-up report. J Arthroplasty 1994;9:595. 6. Mulroy WF, Harris WH. Revision total hip arthroplasty with use of so-called second generation cementing techniques for aseptic loosening of the femoral component. A 15 year average follow-up study. J Bone Joint Surg Am 1996;78:325. 7. Katz RP, Callaghan JJ, Sullivan PM, et al. Results of cemented femoral revision total hip arthroplasty using improved cementing techniques. Clin Orthop 1995;319:178. 8. Malchau H, Herberts P, Eisler T, et al. The Swedish total hip replacement register. J Bone Joint Surg Am 2002;84(Suppl):2. 9. Haydon CM, Mehin R, Burnett S, et al. Revision total hip arthroplasty with use of a cemented femoral component. J Bone Joint Surg Am 2004;86:1179.
74 The Journal of Arthroplasty Vol. 20 No. 4 Suppl. 2 June 2005 10. Dohmae Y, Bechtold JE, Sherman RE, et al. Reduction in bone-cement interface shear strength between primary and revision arthroplasty. Clin Orthop 1988;236:214. 11. Hultmark P, Karrholm J, Stromberg C, et al. Cemented first-time revisions of the femoral component: prospective 7 to 13 years’ follow-up using second generation and third generation technique. J Arthroplasty 2000;15:551.
12. Lieberman JR, Moechal BH, Evans BG, et al. Cement-within-cement revision hip arthroplasty. J Bone Joint Surg Br 1993;75:869. 13. Greenwald AS, Narten SC, Wilde AH. Points in the technique of recementing in the revision of an implant arthroplasty. J Bone Joint Surg Br 1978;60:107. 14. McCallun SD, Hozack WJ. Recementing a femoral component into a stable cement mantle using ultrasonic tools. Clin Orthop 1995;319:232.
Cemented Femoral Revision Lest We Forget Jay R. Lieberman, MD
Abstract: Cemented femoral revisions can provide durable fixation when used for specific indications. These indications include elderly patients with minimal bone loss or large femoral canals and the cement-within-cement technique where a new femoral component is cemented into an intact cement mantle. Key words: cement femoral revision, cement-within-cement technique, intact cement mantle. n 2005 Elsevier Inc. All rights reserved.
The investigators concluded that the results with cemented stems were technique-dependent, and they recommended the use of long stems. Haydon et al [9] recently reported on the results of 97 cemented femoral revision stems that had been followed for a minimum of 10 years. The 10-year survival rate was 91% with aseptic loosening as an end point and 71% with mechanical failure rate as an end point. The mechanical failure rate was defined as the sum of probable radiographic loosening, definite radiographic loosening, and the stems actually revised. Poor bone stock was associated with increased failure. Hips with a category A or B cement mantle showed improved mechanical survival, and third-generation cementing techniques (vacuum centrifugation of cement and distal and proximal centralizers) were associated with a significant improvement in the 10-year survival rate compared with second-generation techniques. In addition, first-generation techniques (hand packing of cement) were associated with decreased survival compared with secondgeneration techniques. The data from the Swedish registry and the study of Haydon et al show that cemented femoral revision can be successful with appropriate patient selection and good surgical technique that results in satisfactory fixation between the cement and bone. The purpose of this review is to highlight the indications for cemented revisions and to provide technical tips that can facilitate a successful cemented revision.
Cementless fixation is the preferred option for most revision femoral components. However, there are specific indications for the use of cemented stems in revision cases. The results of cemented femoral revisions reported in the 1980s were quite poor [1-3]. The loosening rates in these studies were all greater than 12% with a maximum average followup of only 4.5 years. More recent results with midterm follow-up using modern cementing techniques show improved results [4-7]. Although these results were still not equivalent to those reported for cementless fixation, they suggested that there is a role for the use of cemented revision femoral components. Recently, Malchau et al [8] reported the results of the Swedish Registry from 1979 to 2000. The registry reported on 16 577 revision femoral components using cement alone or the impaction grafting technique. The 10-year survival rate for cemented stems was 78%. There was a 3.3 times increased risk of re-revision when the first revision occurred within 5 years of the primary total hip arthroplasty. Men had a 13% increased risk of stem loosening.
From the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California. No benefits or funds were received in support of the study. Reprint requests: Jay R. Lieberman, MD, Department of Orthopaedic Surgery at UCLA, Los Angeles, CA 90095. n 2005 Elsevier Inc. All rights reserved. 0883-5403/05/2004-2021$30.00/0 doi:10.1016/j.arth.2005.03.005
72
Cemented Femoral Revision ! Jay R. Lieberman
Indications The indications for cemented femoral revisions include (1) elderly patients with minimal bone loss or large femoral canals, (2) the cement-withincement technique where a new femoral component is cemented into an intact cement mantle, (3) proximal femoral replacements which are generally reserved for elderly patients with extensive bone loss, and (4) single or 2-stage reimplantation to deliver antibiotics. We will focus on the first 2 indications in this review. The best results with cemented femoral revisions are associated with minimal loss of metaphyseal bone and an intact diaphysis. In elderly lowdemand patients, it is also appropriate to consider using a cemented stem when there is some metaphyseal bone loss and a completely intact diaphysis. This will allow for good cement fixation in the diaphysis. However, extensively porous coated devices will probably provide more reliable results when treating patients with moderate or extensive metaphyseal bone loss. There are a number of technical tips that can enhance results when performing a cemented femoral revision. First, remove the neocortex that forms when a cemented stem loosens [10]. Second, use a long-stem prosthesis that extends 2 to 3 diameters beyond the distal tip of the prior stem [8,11]. Third, use a cement restrictor to enhance cement fixation. Fourth, use antibiotics in the cement (3.6 g in 2 packs of cement). The neocortex must be removed or it will not be possible to obtain adequate interdigitation between the cement and the bone. Recent data have also shown enhanced results when cementing longer stems in place [8,11]. The use of a cement restrictor will enhance pressurization of the cement which is necessary to obtain a durable construct. The cement-within-cement technique for revision of the femoral component can be useful in specific situations [12]. Laboratory studies have shown little loss of sheer strength when applying fresh cement to old cement [13]. The concept is to cement the new femoral stem into a stable cement mantle. Lieberman et al reported on 19 total hip arthroplasties that were revised using this technique. At an average follow-up of 59 months, 18 of 19 patients had a good or excellent result. A prerequisite for this technique is a stable cement mantle. This technique is quite useful in a number of situations including (1) enhancing exposure when performing an acetabular revision, (2) revision of a nonmodular femoral component at
73
the time of acetabular revision to improve offset and stability, and (3) revision of a malaligned femoral component to improve the version of the femoral component. There are a few technical tips that can enhance the results when using this technique. First, select a thinner femoral prosthesis than the previous stem to obtain an adequate mantle of new cement. This new stem needs to have appropriate offset to ensure stability. Second, prepare the femoral canal with either a burr or an ultrasound device [12,14]. This will allow for a larger cement mantle and will increase the surface area between the old and new cement. Third, place the new cement into the femoral canal in the liquid phase to promote integration between the new and old cement. Fourth, use antibiotics in the cement (3.6 g in 2 packs of cement). In summary, cemented femoral stems can be used successfully in elderly patients with minimal bone loss or when using the cement-within-cement technique when there is an intact cement mantle.
References 1. Amstutz HC, Ma SM, Jinnah RH, et al. Revision of aseptic loose total hip arthroplasties. Clin Orthop 1982;170:21. 2. Pellicci PM, Wilson Jr PD, Sledge CB, et al. Long-term results of revision total hip replacement. A follow-up report. J Bone Joint Surg Am 1985;67:513. 3. Kavanagh BF, Ilstrup DM, Fitzgerald Jr RH. Revision total hip arthroplasty. J Bone Joint Surg Am 1985;67:517. 4. Engelbrecht DJ, Weber FA, Sweet MB, et al. Longterm results of revision total hip arthroplasty. J Bone Joint Surg Br 1990;72:41. 5. Stromberg CH, Herberts P. A multicenter 10 year study of cemented revision total hip arthroplasty in patients younger than 55 years old. A follow-up report. J Arthroplasty 1994;9:595. 6. Mulroy WF, Harris WH. Revision total hip arthroplasty with use of so-called second generation cementing techniques for aseptic loosening of the femoral component. A 15 year average follow-up study. J Bone Joint Surg Am 1996;78:325. 7. Katz RP, Callaghan JJ, Sullivan PM, et al. Results of cemented femoral revision total hip arthroplasty using improved cementing techniques. Clin Orthop 1995;319:178. 8. Malchau H, Herberts P, Eisler T, et al. The Swedish total hip replacement register. J Bone Joint Surg Am 2002;84(Suppl):2. 9. Haydon CM, Mehin R, Burnett S, et al. Revision total hip arthroplasty with use of a cemented femoral component. J Bone Joint Surg Am 2004;86:1179.
74 The Journal of Arthroplasty Vol. 20 No. 4 Suppl. 2 June 2005 10. Dohmae Y, Bechtold JE, Sherman RE, et al. Reduction in bone-cement interface shear strength between primary and revision arthroplasty. Clin Orthop 1988;236:214. 11. Hultmark P, Karrholm J, Stromberg C, et al. Cemented first-time revisions of the femoral component: prospective 7 to 13 years’ follow-up using second generation and third generation technique. J Arthroplasty 2000;15:551.
12. Lieberman JR, Moechal BH, Evans BG, et al. Cement-within-cement revision hip arthroplasty. J Bone Joint Surg Br 1993;75:869. 13. Greenwald AS, Narten SC, Wilde AH. Points in the technique of recementing in the revision of an implant arthroplasty. J Bone Joint Surg Br 1978;60:107. 14. McCallun SD, Hozack WJ. Recementing a femoral component into a stable cement mantle using ultrasonic tools. Clin Orthop 1995;319:232.