Cemented Vs Uncemented Hip Replacement

The Artificial Hip Joint

The life span for total hip implants has increased to 20 years or more for 80% of total hip patients. That being said, generally speaking, the more you use the hip joint, the faster it is likely to wear out. It is also important to remember, that this data is based off of older generation implants and techniques. As such, the outcomes may have gotten better in recent years.

The artificial joint, called a prosthesis, is typically made of specialized metal and plastic. The two parts fit together to make a new hip joint with smooth surfaces that glide in a natural and comfortable motion. There are numerous hip prostheses currently on the market. Generally speaking, as far as what is known, they are all pretty much equal. Surgeons have specific implants that they prefer to use mainly based on how they trained, etc. When you decide to undergo surgery, it is recommended that you have the surgeon use the implant that they are most comfortable with, unless there is a specific reason why that implant wouldnt work for you.

Comparison With Other Studies

Use of different implant fixation: time trend

The proportion of total hip replacements using uncemented implants increased rapidly towards the end of the study period. From 2006 to 2010 the proportion of uncemented implants has also increased in several other countries with longer standing register data, such as England and Wales, Australia, Canada, and New Zealand.15 The proportion of uncemented total hip replacements was 44% in England and Wales,814 64% in Australia,9 47% in New Zealand24 in 2011, and 82% in Canada25 in 2010. The majority of total hip replacements in the United States are performed with uncemented implants .16 However, in New Zealand the proportion of total hip replacements using uncemented implants fell for the first time in years, from 52% in 2010 to 47% in 2011, with corresponding increases in fully cemented and hybrid arthroplasties.24 Total hip replacements using hybrid implants are more common in England and Wales8 , New Zealand24 , and Australia9 than in Nordic countries. The proportion of total hip replacements using hybrid implants is decreasing in Nordic countries according to these data, but not in Australia,9 England and Wales8 or New Zealand.24 The proportion of total hip replacements using reverse hybrid implants is increasing in the Nordic countries. In 2011 in England and Wales, 15% of all total hip replacements using hybrid or reverse hybrid implants were reverse hybrids.8

Implant survival

What is already known on this topic

Functional Outcomes Satisfaction And Pain Assessment

Validated patient reported outcome measures were used to assess function pre-operatively and post-operative at 4, 12 and 72 months .

The OHS consists of twelve questions assessed on a Likert scale with values from 0 to 4, a summative score is then calculated where 48 is the best possible score and 0 is the worst possible score .

The Harris hip score is a combine subjective and objective assessment which contains eight items representing pain, walking function, activities of daily living, and range of motion of the hip joint . The collective score ranges from 0 to 100 . The index consists of subjective questions relating to pain and activities of daily living over the previous week and objective assessments of hip function and range of motion.

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Failure Rate Of Cemented And Uncemented Total Hip Replacements: Register Study Of Combined Nordic Database Of Four Nations

Comparison Of Cemented And Uncemented Fixation

The uncemented prosthetic designs were advanced to overcome the complication faced with cemented fixations. Cemented fixation was liable to cement breakage and subsequent inflammation around the prosthesis. The breakage, micromotion, and inflammation may lead to implant loosening.

Bone cement implantation syndrome is a rare complication associated with cementing during joint replacement surgery. The cement material is hypothesized to travel in the bloodstream which may cause difficulty breathing, and cardiac arrest. Pulsatile lavage is aimed to prevent cement and fat globules from leaking into the bloodstream.

The uncemented fixation is not associated with BCIS and the cement osteolysis is not associated with uncemented methods. A well-positioned uncemented implant fixation gets stronger at the interface with time as bone ingrowth occurs, however, loosening may also be associated with uncemented stems.

With a setting time of 10 mins, the cemented implants are fixed instantaneously and patients are able to bear weight right after the surgery. However, in the case of uncemented stems, only partial weight-bearing is allowed initially as the bone ingrowth takes at least 3 months. However, with recent changes in implant designs and techniques, some surgeons may allow weight-bearing right after surgery even in uncemented fixations.

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A Brief History Of Cementing

German surgeon Themistocles Gluck who, proposed the use of bone-cement in arthroplasty. The previous year in Berlin, he had performed the first total joint replacement using a hinged, ivory prosthetic knee. He had also developed models for shoulder, elbow, and wrist arthroplasties. To secure these to bone, he experimented with a variety of materials including copper amalgam, plaster of Paris, and stone putty.26 Although his efforts were remarkably successful in the short-term, they invariably failed due to infection or loosening, and ultimately he gave up his work on prosthetics to pursue other areas of medical research.

Pioneering work in the field of PMMA technology is credited to German Chemist Otto Röhm, who patented Plexiglas in 1933. In the lead up to World War One, interest in this material and its use in submarine periscopes, gun turrets, and aeroplane canopies grew significantly.27 In 1936, the German Kultzer Company found that a mixture of methyl methacrylate monomer and ground polymer produced a dough that could be molded and polymerized to a solid mass by heating in the presence of benzoyl peroxide.28,29 They went on to develop cold-cured PMMA, which hardens at room temperature. Following this, the use of acrylic resins for dentures and cranioplasty prostheses developed during the 1940s.29

Cemented Joint Prostheses: Advantages And Disadvantages

A cemented prosthesis is designed to have a layer of bone cement, typically an acrylic polymer called polymethylmethacrylate , in between the patient’s natural bone and the prosthetic joint component.

There are a few advantages to using bone cement in joint replacement surgeries:

• Bone cement allows a surgeon to affix prosthetic joint components to a bone that is slightly porous from osteoporosis.
• A small amount of antibiotic material can be added to the bone cement, helping to decrease the risk of post-surgical infection.
• The bone cement dries within 10 minutes of application, so the surgeon and patient can be confident the prosthetic is firmly in place.

The drawback to using bone cement is that it may degrade over time and bits of cement can break off, potentially causing problems:

• A breakdown of the cement can cause the artificial joint to come loose, which may prompt the need for another joint replacement surgery .
• The cement debris can irritate the surrounding soft tissue and cause inflammation.
• While rare, the cement can enter the bloodstream and end up in the lungs, a condition that can be life-threatening. This risk is greatest for people who undergo spinal surgeries.

Exactly how often these complications occur following specific types of joint replacement surgeries is uncertain. Not all patients with bone cement debris experience symptoms. Bits of cement debris can be removed arthroscopically to alleviate or prevent symptoms.

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To Cement Or Not To Cement Acetabular Cups In Total Hip Arthroplasty: A Systematic Review And Re

Frank Van Praet1* and Michiel Mulier2

1Master of Medicine, KU Leuven, Bergsken 50, 9310 Moorsel, Belgium 2Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium

Accepted: 22 August 2019

Abstract

Key words: Total hip arthroplasty / Cemented versus hybrid / Revision rate / Functionality / Cost

This is an Open Access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Cementless Joint Prostheses: Advantages And Disadvantages

A cementless prosthesis, also called a press-fit prosthesis, has a rough surface or porous coating that encourages the natural bone to grow onto it. New bone growth will span only 1 or 2 mm, so the surgeon must use special tools to shape the natural bone to fit snugly with the prosthesis.

Some prosthetic components have screws or pegs that help hold the bone and prostheses in place until new bone growth can create a more secure attachment. For example, during some shoulder replacement surgeries, the new shoulder sockets are backed with short pegs that fit into the patients’ natural bone, thereby helping to stabilize the new prosthesis and the patient’s scapula .

A number of surgeons prefer cementless components because:

• They believe cementless components offer a better long-term bond between the prostheses and bones.
• Cementless components eliminate worry about the potential breakdown of cement.

The downsides to cementless prostheses are that:

Because it takes time for the natural bone to fully adhere to the new joint components, experts debate whether or not patients should postpone putting their full weight on new joints.

Cemented Versus Uncemented Stems In Total Hip Arthroplasty In Patients With Femoral Neck Fractures

The purpose of this prospective randomized study is to compare the quality of treatment between cemented versus uncemented hydroxyapatite coated femoral stems in Total Hip Arthroplasty in patients who suffers from dislocated femoral neck fractures.

Our hypothesis is that an uncemented option spares the patient the operative load of the cementing procedure, i e risk of fatty embolism and inflammatory response, which in turn also perhaps reduces the postoperative cognition strain and improves mobilization parameters.

If the uncemented option has the same excellent fixation in poor bone stock, as in the case of these osteopenic fractures, and also has the same good clinical outcome, it would be a viable standard option for the treatment of dislocated femoral neck fractures.

As a measure for reducing those risks an uncemented hip arthroplasty is sometimes used instead.

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Is The Outcome Of Tha Determined By Fixation Method

When looking at outcomes of THA, it is clear that the results are multifactorial. It is also important to appreciate that the ultimate outcome that is of interest is the health and economic gain to the individual and society, respectively. In order to optimize this, surgeons should look towards improving patient selection and minimizing complications. Surgical training and experience are key to the success of this. When important decisions such as type of fixation to choose for individual patients is made based on patient age rather than bone quality, medical comorbidities, and surgeon experience, one is deterring from the ultimate goal of arthroplasty namely improving individual patient outcomes that translate to health and economic gain to society.

The Swedish Hip Joint Replacement Register

The Swedish Hip Joint Replacement Register was established in 1979. The register is a combination of two sub-registers: one for surgery with total hip replacement with osteoarthritis as the primary indication, and one for surgery with hemiarthroplasty with femoral neck fracture as the main indication. The latest annual report was released in 2014 .

Sweden is currently the only country in the world where cemented stems are regularly used in primary THAs. In the early 1990s, due to the poor results of cementless fixation, the use of cemented stems staggered and reached its peak as 9293% of all THAs during 19982000. Since then the cementless stems regained popularity thanks to the improvement in prosthesis design and surgical skills. The proportion of cemented stems has declined steadily. In 2014, the percentage of cemented stem declined to 64.6%, but still it was higher than any other countries in the world. The percentage of cementless stems was 20.9% in 2014 and most of them were performed in young patients less than 60 years old. The percentage of hybrid stems was small and didn’t change much during a 10-year period.

If stratified by different age groups, cemented stems were used in all age groups, especially in patients 60 years or older . Cementless fixation, hybrid or reverse hybrid fixation, on the contrary, were mostly performed in young patients less than 60 years of age.

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Does Cement Have Any Significant Drawbacks

The argument of using cement in poor bone quality may be catastrophic in patients with low cardiovascular reserve who are receiving a cemented component.12 This is due to the poorly understood bone-cement implantation syndrome and the mortality associated with it.13,14 It has been recorded to cause a number of clinical features from hypoxia, hypotension, and cardiac arrhythmias to increased peripheral vascular resistance and cardiac arrest.12,13,15 While the mortality from use of cement during hip arthroplasty may not be proven, the need for mitigating this risk is well recognized.14

In conclusion, based on the literature, it is hard to justify mandating one particular method of implant fixation in all patients. While cost should be one of the factors that decide the use of implants, it should not be the main driving force. Decision-makers should increasingly seek to identify those patients for whom technology is most cost-effective but should also acknowledge that clinicians may be better equipped at making this decision at the bedside. It is important to understand that the perceived gain in costs of cemented implants is variable based on institution volume and procedural costs. While chronological age may be a surrogate for bone stock, it does not define the quality of bone.

Inclusion And Exclusion Criteria

We included patients aged 55 years or older with a stemmed implant for total hip replacement . Overall, the Nordic Arthroplasty Register Association database contained data on 536 962 hip replacements. If a patient had both hips replaced, we included data for only the first owing to potential bias of bilaterality.2223 We also wanted to ensure that the analyses were not biased by potential errors in recording laterality. In total we excluded 3227 hip resurfacings, 88 723 hip replacements owing to bilaterality, 38 procedures that were not primary operations, and 49 424 owing to young age . We also excluded three patients aged more than 100 years because of suspected coding errors and 1694 hip replacements because the type of fixation was not mentioned. We excluded 20 hip replacements because of ambiguity over the laterality of the first operation, 45 208 because the procedure was undertaken for hip fracture, and 726 owing to a missing diagnosis. Altogether we included 347 899 total hip replacements: 232 603 using cemented implants, 71 454 uncemented, 28 215 hybrid , and 15 627 reverse hybrid .

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Revision For Any Reason

When comparing cemented with hybrid models, the risk of revision for any reason was not significantly different in five and significantly smaller for cemented models in two studies. In these last two studies, results were significantly more favourable for cemented than for hybrid prostheses, irrespective of age. In patients aged 3555 years, there were 65% more revisions during the first two years for hybrid compared to cemented implants, after which this effect decreased to 35% . This effect remained significant for up to 16 years postoperatively. In this study, dislocation was the main reason for revision during the first two years . A second study found the same significant effect five years after the procedure . For the five remaining studies, the trend also was slightly more favourable for cemented prostheses, but no significance levels were achieved. Not a single study could show a significantly lower risk of revision for any reason for hybrid compared to cemented models.

When comparing all the cemented with all the cementless cups , a single study concluded that there was a significantly higher risk of revision during the first year after cementless fixation of the cup in patients more than 80 years of age . However, this protective effect of a cemented socket was no longer present five years after the procedure .