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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 138-144

Ten years' follow-up for cemented hip arthroplasty in patients <60 years of age with standardization of cementing technique: A multicentric study


1 Department of Orthopaedics, F.H. Medical College and Hospital, Agra, Uttar Pradesh, India
2 Department Of Orthopaedics, Hamdard Institute of Medical Science and Research (HIMSR), New Delhi, India
3 Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India
4 Department of Orthopaedics, Northan Railway Divisional Hospital, New Delhi, India
5 Department of Orthopaedics, Centre for Trauma and Joint Replacement, Agra, Uttar Pradesh, India

Date of Submission18-Feb-2022
Date of Decision11-Mar-2022
Date of Acceptance16-Mar-2022
Date of Web Publication1-Sep-2022

Correspondence Address:
Sabeel Ahmad
Department of Orthopaedics, F.H. Medical College and Hospital, Agra, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_12_22

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  Abstract 


Introduction: Total hip arthroplasty (THA) is the preferred treatment for persistent disability due to hip pathologies and restoration of normal functions. Although there is a general consensus of using un-cemented implants for adults and elderly with good bone quality and cemented for senior citizen population, implant choice for middle aged group of 40 years to 60 years is still a subject of debate, especially in financial constrained situations. In our study, we have determined the implant survivorship and functional outcomes of cemented THA in patients between 40 and 60 years of age, at the minimum follow-up of 10 years with emphasis on standardization of cementing technique. Materials and Methods: This is a retrospective study including 25 patients who had undergone cemented hip arthroplasty. Data were collected from five different surgical centres, whose orthopedic surgeons had common surgical training and were following a common cementing technique. Results: Mean Harris Hip Score of 25 hips at final follow-up was 90 and Visual Analog Scale 1.88. The functional outcome was good to excellent at final follow-up in 89% hips. There was a significant improvement in pain and activity level after surgery (P < 0.001) and maintained at the final follow-up. Conclusion: Our series provides evidence for utility of cemented hip implants in low functional demand patients along with emphasizing the importance of a good cementing technique for the long-term survival of cemented hip arthroplasty in the age group of 40–60 years.

Keywords: Cementing technique, survivorship, total hip arthroplasty


How to cite this article:
Sajid I, Jameel J, Singh S, Singh SP, Varshney A, Ahmad S. Ten years' follow-up for cemented hip arthroplasty in patients <60 years of age with standardization of cementing technique: A multicentric study. J Orthop Dis Traumatol 2022;5:138-44

How to cite this URL:
Sajid I, Jameel J, Singh S, Singh SP, Varshney A, Ahmad S. Ten years' follow-up for cemented hip arthroplasty in patients <60 years of age with standardization of cementing technique: A multicentric study. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Dec 3];5:138-44. Available from: https://jodt.org/text.asp?2022/5/3/138/355235




  Introduction Top


For humans, hip joint has as paramount importance for their day-to-day activities to provide maximum range of motion in multi-planar axis to transmitting body weight; this joint has maximum load bearing forces for a long period. Any pathology of the hip is much debilitating for patient as its affects their gait pattern and mobility.[1],[2] Total hip arthroplasty (THA) is the most productive procedure and choice for long-term pain relief and restoration of normal function in pathological hips. Hip replacement can be cemented or noncemented. In cemented THA, polymethyl-methacrylate (PMMA) is used between bone and implant. PMMA modulus of elasticity is very similar to the bone and resistant to compressive forces but not to shear and strain.[3] Survivability of cemented arthroplasty mainly depends on the quality of cementation. Long-terms failures of cemented arthroplasties are due to the formation of osteolytic areas.

Immediate fixation of uncemented prostheses depends on primary fixation or macro-locking. Macro-locking occurs at the time of prosthesis insertion which provide snuggly adjustment of prosthesis with bone that may be strengthened by fins, grooves, or screws.[4],[5] Long-term survivorship of un-cemented THA depends mainly on osteo-integration/micro-locking. Osteo-integration mainly result of bone ingrowth and lead to bony bridge formations between implants pores and bone. It is very controversial topic to compare the efficacy of cemented prosthesis with un-cemented in THA. Universal consensus regarding superiority of un-cemented THA in young adults may require revision.[4],[5],[6],[7],[8] However, in old age, around 50 years with moderate activity level; cemented THA becomes a viable option. There are many factors which can influence the survivorship of both cemented and un-cemented implants are geometry, materials, surface finishes, and bearings.[6] Moreover, study-specific factors such as surgical approach, techniques, and study design also play an important role in survivorship.[6] In this study, we determine the implant survivorship and functional outcomes of cemented THA in patients <60 years of age at a minimum follow-up of 10 years with emphasis on standardization of cementing technique.


  Materials and Methods Top


It is a retrospective study in which radiographic review with proper follow-ups of patients who underwent cemented THA. Data were collected from five surgical centers [Table 1], whose orthopedic surgeons had common surgical training and were following a common cementing technique (at the end details of surgeons and data collected from different hospital given). All patients between the ages of 40 and 60 undergoing primary cemented THA. Between January 2001 and January 2010 were reviewed.
Table 1: Data of 5 centers (according to the title page)

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Inclusion criteria

Primary hip pathology (Avascular necrosis of femoral head (AVN), Ankylosing spondylitis (AS), Rheumatoid Arthritis (RA), Osteoarthritis (OA), and septic/infective sequelae), age 40–60 years of age, lower socioeconomic strata, and lower functional demands.

Exclusion criteria

Age <40 or >60 years, developmental dysplasia of hip, bone defect in acetabulum/femur, and revision surgery.

THA was performed in 34 patients. Nine patients were lost to follow-up, 25 hips left for this study. The mean age was 49 (39–59) years. The minimum follow-up was 10 years. Demographically, 25 cases were taken, of which 17 were male and 8 were female, 20 hips right and 5 left in which 12 AVN [Figure 1], 2 osteoarthritis, 5 ankylosing spondylitis, 4 rheumatoid arthritis and 2 old infective sequelae [Table 2]. All the surgeries were performed by 5 consultant orthopedic surgeons using posterior moor's approach. A standardized cementation technique was used by all surgeons.
Figure 1: Preoperative radiograph of pelvis with B/L hip suggestive of AVN right femoral head (FicatArlet Stage 3), postoperative day 1, check the cement penetration in the acetabulum and total “white out” of femoral component with distal cement plug

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Table 2: Demographic details

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Patients reviewed at 6 weeks then 3, 6, 12 months, followed by 2, 5, 7, and 10 years. Visual Analog Scale (VAS) and Harris Hip Score (HHS) were used as measuring tools of functional outcome and score <70 considered as a failure [Table 3]. Pain recorded by VAS score. Radiographs were taken at every follow-up [Figure 2]. All the radiographs were analyzed for signs of implant failure, wear, and loosening [Figure 3]. Femoral loosening defined by Harris classification, probable and possible (Harris et al. 1982).[36] Progressive radiolucent lines in 2 or more Charnley and De Lee zones were considered the signs of loosening in the acetabulum (De Lee and Charnley 1976).[37] The change in implant position or migration and eccentric wear of the cup were also considered the signs of implant failure.
Figure 2: Sequential follow-up radiographs: At 1, 5, 7, and 10 years, respectively, shows excellent result without loosening and dislocation of implant. From same patient

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Figure 3: (a) Radiographs of aseptic loosening of left femur with left acetabulum at risk 2 years follow-up, (b) Acetabulum - No interdigitating of cement in the bone with normal femoral component, (c) 15 months' follow-up showing lucency at Cup - Bone interface - Slippage of cup as compared to earlier radiograph. Different patients have different complications which are shown here

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Table 3: Visual Analog Scale and Harris Hip Scores at different time periods

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Standardized cementation technique

Main aim for cementing is to penetrate the cement deeply and densely into trabecular bone to form a strong mechanical interlock. Third generation cementing used pulse lavage, distal cement restrictor and centralizer, retrograde cement application, acetabulum pressurizer in all the cases. For acetabulum, high viscosity cement (smart-set) is used and for femur routine cement (low viscosity).

Acetabular cementing

Because of large surface area of acetabulum with wide opening and a discontinuity in the wall under the transverse ligament, this is difficult to hold the cement that's why cement application is done when cement is nonsticky and can be rolled in a ball shape. Timing of cement application and cup introduction influences cement penetration because of time-dependent changes in the viscosity of the cement. The basic principle is that the lower viscosity, better the penetration (Krause et al. 1982, Noble and Swarts, 1983, Stone et al. 1996).[38],[39],[40] However, it is more difficult to handle at low viscosity and acetabulum leakage around the edges becomes more of a problem, thus putting higher demands on transforming the cavity into a closed space during cement pressurization, so antibiotic mixed smart set cement (high viscosity) is generally used for acetabulum.

Acetabulum preparation

Taking all universal precautions painting and draping done. Standard operating theater with laminar flow, Moore's approach used to reach hip joint. Acetabulum prepared by obtaining cancellous bed of bleeding bone using sequential hemispherical reamers of increasing diameter. Multiple drill holes (dia-0.5 and depth 1 cm) were made in the acetabular bed to increase the surface area for cement. Pulse lavage used to remove debris and a hydrogen-peroxide soaked swab followed by dry swab was inserted into the acetabulum before cementing to create a dry surface for cementing.

Cement preparation

Prechilled smart set cement was used for acetabulum [Figure 4]. Manual method of mixing in a bowl with spoon, as vacuum mixing was not available at all centers. Once the monomer (liquid) is poured over the polymer (powder) in a bowl, a timer started. A strict protocol of slow uniform mixing was followed, so air bubbles formation could not happens during the mixing, resulting in a homogeneous mixture without affecting viscosity. Mixing takes 2–3 min and leads to a sticky liquid which is a waiting phase. At this waiting phase (usually lasts 2–3 min), surgical gloves to be changed so that the blood on surgical gloves does not mixes with the cement.
Figure 4: Cement kept in the refrigerator, cement in powder form, smooth and slow mixing of cement in liquid form, liquid cement loaded in cement gun (ready for femoral cementing)

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Cement application

Working phase when sticky cement converted to nonsticky dough and loses its shiny sheen to a dull texture. Working phase usually lasts 10–15 min, with prechilling further extending. Cement is applied through fingers in the acetabulum cavity and special emphasis is given over the medial load bearing bone. Cement is pushed in acetabulum through fingers. Pressurizations result in greater penetration of the bone, improves bone cement interface. A pressurizer is used [Figure 5]a to give a uniform pressure for at least 30 s before cup implantation so that the cement goes deep inside the trabecular of acetabulum bone. Cup is inserted and maintained in its intended inclination and version till the cement hardens. Whole process of cement mixing to cement hardening usually takes around 15–18 min with around 10–12 min as the working phase.
Figure 5: (a) 360° view of acetabulum showing peg holes, nonsticky cement rolled in a ball shape; Balled up doughy cement pushed into the acetabulum and uniformly spread using fingers, use of cement pusher to spread the cement inside bone and indentation holes. Cement Pushers - Blue dome used direct on cement and SS dome used over the acetabulum cup, (b) Cement restrictor insertion, cement inserted in the canal by using cement gun, stem being inserted into the canal after cement insertion, stem maintained in correct version with a finger acting as proximal seal to prevent cement escape

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Femur cementing

Femur preparation

After box cut femoral canal broached and cleaned with pulse lavage to remove the fat, blood and debris. Lavage reduces the chance of fat embolism and pulmonary complications which must be done before any instrumentation in the medullary cavity.[9],[10],[11] After lavage, canal should be plugged with cement restrictor. This ensures a well-defined close cavity for good filling of the cement and pressurization to reduce physiological disturbance while prosthesis insertion.[12] After suctioning, the canal is studded with hydrogen peroxide-soaked gauze along with infant feeding tube while cement is being prepared.

Cement preparation

Prechilled low viscosity cement used for femur. Rest same as above in acetabular cementing. Mixing usually takes 2–3 min and leads to a sticky liquid which is a waiting phase. The sticky liquid is filled in cement gun.

Cement insertion

After removing the hydrogen peroxide-soaked gauze and leaving the infant feeding tube connected to suction inside the canal, cement is introduced in to canal, retrograde manner with a cement gun and a proximal seal (finger over the canal) to maintain pressure. The pressure has to be maintained until viscosity is enough to resist cement extrusion. Suction through the infant feeding tube helps in removing any air bubbles/blood. Any excess cement is pushed back inside the canal through digital pressurization.

Stem insertion

Stem is inserted in the desired ante-version and to the preplanned depth with a small cuff of cement around the distal tip of the stem. The design of the stem along with its polished nature helps to pressurize cement during stem insertion. Pressure is also maintained by placing thumb over calcar while implant insertion thus preventing cement extrusion then left cement placed around neck to strengthen the collar. A continuous pressure on the stem in desired version is maintained until cement polymerization is complete [Figure 5]b.

Statistical analysis

Paired t-test used to see the postsurgical improvement and KaplanMeier graph to determine the survivorship of implants; P < 0.05 used as to measure statistical significance.


  Results Top


Demographic data with preoperative diagnosis and sample size are given in [Table 2]. Mean HHS at the final follow-up was 90. Looking at HHS, functional outcome was good to excellent at the end of study in 89% hips. There was significant improvement in pain (VAS-1.88 [Standard deviation]) and activity level after surgery (P < 0.001) that maintained at the final follow up [Table 3]. Most common complication noticed that stitch line infection (in 2 patients) [Table 4]. All were managed by local debridement and antibiotics. Two cases had postoperative dislocations which were managed with closed reduction and a boot bar application. Both patients had good HHS at 2 years follow-up. Radiographic finding at final follow-up showed loosening of femoral stem in one patient and acetabular component in another. Revision surgery planned for these two patients. Survivorship at the end of the study using the Kaplan − Meier graph found to be 97% (97% confidence interval [CI] 95–98). In those patient who had undergone revision surgery, survivorship dips up to 83% (95% CI 79–86).
Table 4: Complications

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  Discussion Top


THA as the treatment of choice for hip pathologies since a long time in the literature. With the time cost of implant also has increased. But still, there is a lot of debate over the choice of THA-cemented or un-cemented. The advantage of using bone cement in hip arthroplasty is achievement of initial stability of the implant. Dr Charnley published six cases of cemented THA in J. Bone and Jt. Surg. in 1960[13] emphasizing that cement function as grout rather than glue, which fixes the implant by interlocking rather than adhesion that fills every crevices and slits in the interior of femoral canal which leads to transmit the patient's body weight over large surface area of bone and prevent implant failure.[12],[13]

Potential risk of cementing is cardiopulmonary disturbance, called “bone cement implantation syndrome.”[8],[9],[10] Aseptic failures of cemented arthroplasties were thought to result from a biologic reaction to the cement, and term “cement disease” was given, but it has been proved due to polythene debris.[11] Charnley's hip arthroplasties showed good result with and incidence of mechanical failure at bone-cement interface is 2.2% at 8 years of follow up.[14] In early days of THA, very little significance was given to the cement technique. Work from Robin Ling in Exeter and John Charnley in Washington enlightened the mechanical properties of bone-cement and importance of cementing technique to increase the survivability of THA. Bone-cement acts as grout, making the mechanical interlock between interior of bone and prosthesis, which lead to transmit the physiological load to bone.[15] It leads to form extensive micro-interlocks which are the key success of cemented prosthesis. These interlocks optimize the load carriage to bone and reduce the stress during repeated cycles of loading and unloading, this reduces the formation of bio-membrane/fibrous tissue at bone-cement interface thus decreases the chance of implant loosening.[15]

Modern cementing techniques have improved survivorship in younger patients as well.[16],[17],[18] Both pressurization and lavage of cancellous bone have been identified to be the most significant factors with regard to improved cement interdigitating with bone.[19],[20],[21],[22]

Polymerization of cement has a direct relationship with temperature. Debrunner and Wettstein[23] seen that increasing the room temperature by 10° C (18°F) decreased the time to set by a factor of one and half to two and vice versa. Because it is often difficult for a surgeon to control the temperature of the operating room, the monomer, the powder and the mixing vessels should be cooled. In our study we have precooled the cement monomer for all cases which gave us the working time for cement close to 10 min.

Aim of cementing is to achieve total “white out” for femoral component as given by Barrack's femoral cementation quality grading system.[24] many clinical studies comparing patients before and after the introduction of modern cementing techniques have confirmed the benefit of improved cement application techniques;[25],[26],[27],[28],[29] and the same benefit being seen in young patients also.[17],[18] Further if the revision risk is considered as measured outcome, the Swedish Hip Registry has provided the evidence to support this relationship.[26] it's also considered that modern cementing technique including distal and proximal cement restrictor, pulse lavage, cement gun for cementing and thorough canal cleaning (4th generation cementing) play important role to reduce the risk of revision surgery by approximate 20%.[30] For all our cases we have followed the same. Our results are comparable to studies.[31],[32],[33],[34],[35]

HHS, VAS scores and functional outcome of our study is good to excellent at final follow up which is comparable with other series from different specialty centers or teaching hospitals with long term follow up (Lehtimäki et al. 1997, Goodman et al. 2014).[41],[42] Majority of our patients were pain free and well-functioning hips at final follow up [Table 3]. In this series deep infection was negligible (0%) comparing with others 1.2%–8% (Wroblewski et al. 2009, Warth et al. 2014).[43],[44]

Get it right first time reported by British Orthopaedics Association recognized the need of THA implants for standardize use in the National Health Service with more towards cemented once (Briggs 2012).[45]

Short coming of our study is small sample size, though surgeons learned from same institute but different set-ups could have discrepancies but not major accepted by Author. Another relative weakness is varied diagnosis included, which mimics variety of pathology in this age group that requires THA.


  Conclusion Top


The correct cementing technique is important for the longevity of the cemented implants. Our series provides evidence for the utility of established cemented hip implants for low socioeconomic status and moderate-to-low functional demand of the patients, along with identifying standard cementing technique which if followed, has proven the best long-term survival of cemented hip arthroplasty in young adults.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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[PUBMED]  [Full text]  
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Materials and Me...
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Conclusion
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