Modern Cementing Technique Knee arthroplasty

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A brief summary – Improved results in hip and knee joint arthroplastyImprovements in implant design, manufacturing proce-dures, infection prophylaxis and surgical technique are main reasons for the significant reduction in failure rates in joint arthroplasty, as observed during the last decades. However, the improvements in cementing technique are also a major contributing factor to this reduction.1,�,3

Prerequisites for long term survival in cemented joint arthroplastyIn cemented knee arthroplasty, the short and long term fixation depends on the quality of the bone bed, implant design and positioning, intrinsic properties of the cement and the bone cement interfaces, i.e. penetration of ce-

ment into the cancellous bone bed.

Finally, post polymerization removal of excess cement and meticulous joint lavage, may prevent cement related “third body-wear” responsible for clinical failure and ex-cessive polyethylene-wear.

The aim of this educational material is to increase under-standing of the following elements of Modern Cementing Technique.

• Bone Cement

• Mixing and Delivery

• Bone bed preperation

• Pressurization

• Safe working environment

Modern Cementing Technique – Knee arthroplasty

Modern Cementing Technique – Important aims and solutions

Aims

Reduced risk for infectionAntibiotic loaded bone cement re-duces the risk of infection in both primary and revision operations

Clean Bone Bed for improved bone cement interface.

High Pressure Pulse Lavage.A vital step to achieve a proper cement penetration and fixation into the cancellous bone.

High and reproducible bone cement quality, with reduction in porosity and improved fa-tigue strength.

Mixing and collection under vac-uum. Adequate cement filling with cement gun.

Proper cement filling with correct instrumentation

Proper fixation and improved bone cement interface yields good stress distribution

Safer working environment. Reduced risk for surgeons and nurses.

Closed vacuum mixing system reduces skin and air exposure to bone cement and monomer fumes

Solution

SUMMARY

� · S U M M A R Y

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Modern Cementing Technique – Reducing the risk of failureCorner stones in Modern Cementing Technique – Knee

Preparation of cancellous bone surfacesSurface preparation, including meticulous high pressure pulse lavage, is a prerequisite to achive bone cement micro-interlock, which enhances the mechanical bond between cement and bone.

Cement applicationUse a nozzle and deliver vacuum mixed bone cement at adequate viscosity to dry cancellous surfaces. A pressurizer can be used to increase cement penetration and distribution in the cancellous bone. Additional cement can also be applicated directly to the implant if this is preferred by the surgeon.

Cement mantleA uniform, �–3 mm bone cement mantle ensures optimal fixation and stress distribu-tion

Removal of extruded cement Excess cement may cause pain and abrasive wear.

High pressure pulse lavageIrrigation reduces the risk of polyethylene thirdbody wear.

SUMMARY

S U M M A R Y · �

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Pre-requisits for a reproducible cementing technique to optimize implant fixation.

Pre-operative planningThis is always necessary for custom implants, balancing procedures, osteophyte removal, bone transplants and the removal of internal fixation devices (after tibial pla-teau fracture, osteotomy, ligament reconstruction etc.). Standard X-rays are used for pre-operative planning (AP, lateral projections).�

Surgical exposure and balancing The exposure should not restrict the visual field but rather expose resected bone surfaces for direct visual overview (Fig 1). Careful surface preparation and proper implant sizing (maximum coverage of the cut tibial surface) and removal of extruded cement5,6 is important (Fig �-�).

Proper balancing includes the removal of osteophytes. Improper balancing carries a risk of tibial and femoral implant malpositioning and tibial-tray “lift off.”7

Intra and post-operative bleedingUse of a tourniquet during total knee arthroplasty is common practice.

Bleeding may reduce cement interdigitation into the trabecular bone8,9 and thus weaken the strength of the bone cement interface. To prevent this bleeding, the use of a high pressure pulsative lavage system and high viscosity bone cement10,11 applied to dry bone is recommended.

Postoperative bleeding is reduced by sealing of the femoral intramedullary guide hole with a bone plug.1�

(Fig 5-6) Finally, tranexamic acid reduces early post-operative blood loss and need for blood transfusion in patients undergoing TKA.13,1�

ImplantThe tibial base-plate peripheral lip prevents escape of cement and improves cement penetration at the pe-riphery of the component in metal backed tibial com-ponents.15 (Fig 7) Grit-blasted titanium surfaces yield maximum implant-cement interface strength.16

Implant surfaces should be kept dry as wet surfaces impair the cement-metal interface fixation strength.17, 18

(Fig 8)

Fig 1 Fig �

Fig 3 Fig �

Fig 5 Fig 6

Fig 7 Fig 8

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Bone bed preparation Technique

TibiaVisual overview enables the surgeon to recognize improper cuts, bone defects, sclerotic bone and cysts. In sclerotic bone, supplementary anchorage holes may increase the contact area between bone and cement, providing enhanced fixation. Cysts are curetted and the pericystic sclerotic walls removed. Depending on cyst diameter, patient age and activ-ity level, bone defects are then filled with bone ce-ment or particulate bone graft.

A most important step is high pressure pulse lavage of the entire resected bone surface.�,�0

FemurContained defects can be grafted with bone taken from the cut surfaces.�1 In sclerotic bone, supple-mentary anchorage holes are drilled. Thorough lavage of all surfaces is performed. Before cement application, bone surfaces are kept dry, including the posterior aspect of the femoral condyles.

PatellaIf the resected bone surface is hard and sclerotic, supplementary anchorage holes may be drilled.

Inadequate bone stock, especially severe excavation is a relative contraindication to patella resurfacing.

Micro-interlock – bone-bed preparationThe overall purpose is to achieve micro-interlock of the bone cement interfaces (i.e. intimate cement-trabecular bone interdigitation), and ensure an even cement mantle with proper bone cuts.19

Modern cementing technique

The ingredients in modern cementing technique are high pressure pulse lavage for cleaning, pressurization devices for adequate cement application, and mixing of cement under vacuum.

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Cement mixing and delivery

�0g of cement is normally sufficient for TKR (�x�0g when cementing the components in two sequences).

The cement can be pre-chilled if a longer working phase is required.

Mix cement in a closed vacuum mixing system.

The use of a cement gun with an adequate nozzle is rec-ommended in order to minimize the risk of air and blood entrapment and achieve sufficient pressurisation

Inclusions of blood and laminations in the cement mass reduces the mechanical strength of the resulting cement mantle.��, �5

Bone CementHigh quality cement is recommended.

The viscosity of the cement affects the strength of the cement-bone interface. High viscosity cement is more effective in displacing bone marrow and preventing he-modynamic back-flow, thereby providing better apposi-tion and resulting in stronger interfaces.11

In hip arthroplasty, the use of antibiotic-loaded cement has lowered the infection rate by approximately 50 %.�� It is therefore recommended that antibotic-loaded ce-ment also be used in knee arthroplasty.

The surgeon should be familiar with the viscosity and cur-ing time (polymerization phases) of the cement used.�3

The cement is applied on dry bone and implant surfaces. Use a cement gun and adequate nozzle.

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Implant introductionThe components may be cemented sequentially or si-multaneously. The components are inserted and driven into position with impactors, followed by trial liner inser-tion and compression with the leg lift method.�6

Excess cement removalAfter compression, and before polymerization, excess cement is removed. The tibial base plate surface is cleaned as cement debris may impede liner insertion and promote third body polyethylene wear.�7,�8,�9

Post-polymerization high pressure pulse lavage (> � L) is effective in removal of bone and cement debris avoid-ing third body wear of polyethylene.30 The final liner is inserted.

Insertion of tibial component

After implant insertion extruded cement is removed.

Cement removed from implant peripheries.

After polymerization remaining cement flakes at implant peripheries are removed.

Cement debris is removed by high pressure pulse lavage.

After irrigation the final liner is inserted.

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Full- versus surface- cementation technique Controversy exists regarding the optimal ce-menting technique of the tibial component. The stability of surface-cemented tibial components is related to the depth of the cement penetration.�6 If a satisfactory penetration (> 3 mm) is achieved, then stem cementation has been shown to have no added advantage in biomechanical cadaver studies and clinical follow-up examinations.

If the cement mantle penetration cannot be guaranteed due to significant bone defects or hard sclerotic bone, then the tibial stem should be cemented together with the undersurface of the tibial tray.31,3�,33

Postoperative radiographic evaluationBoth A-P and lateral views are necessary in order to evaluate cement penetration, and detect radioluencies and extruded cement at implant peripheries.

Follow-up in national registersImprovements in surgical technique, cementing tech-nique, implant design and perioperative regimes (i.e. antibiotics) can be monitored using survival data in na-tional registers.

Arthroplasty registers are an important part of quality control and research after TKA.

Cementation of the tibial tray undersurface only.

Cementation of the undersurface of the tibial tray and stem.

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Safer working environment – A growing demand from surgeons and nurses. Increased awareness among surgeons and nurses has led to a growing demand for safety in the workplace.

Some of the more important factors to consider are the following

• Minimize the exposure of monomer fumes when mixing cement

• Avoid direct contact with bone cement during mixing and delivery.

• Minimize (avoid) cement cloud with antibiotics

• Avoid direct exposure to PMMA and MMA.

• Be aware of to risks when breaking glass ampoules (injuries/glass debris)

• To prevent contact allergy, protective gloves are recommended. Latex gloves provide no protection from monomer penetration.

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The use of a closed vacuum mixing system is recommended.

Protective gloves are recommended.

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Cementing University – There is always more to learn Within the orthopaedic community there is increasing focus on Modern Cementing Technique. New studies and publications have dramatically increased our knowl-edge and awareness of the importance of bone cement and cementing techniques. The Cementing University is a forum for training and education. It aims to spread knowledge about Modern Cementing Technique and to emphasize the importance of bone cement and cement-ing techniques.

For more information about education, our courses and seminars, please visit any of the following websites:

www.biomet.com www.bonecement.com www.cementinguniversity.com www.biometosa.com

Cementing University is a brand within Orthopaedic Skills Academy, which is Biomet’s official educational programme for healthcare providers in the orthopaedic community.

This brochure is accredited by AfPP (The Association for Perioperative Practice). An evaluation form is avail-able on www.cementinguniversity.com

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Swedish Total Hip Replacement Register.JBJS �00�; 8�A: �-�0

�) Ritter MA, Herbst SA, Keating EM, Faris PM. Radiolucency at the bone-cement interface in total knee replacement. JBJS 199�; 76A: 60-65.

3) Lidgren L, Robertson O. Acrylic bone cements: clinical developments and current status: Scandinavia Orthop ClinN Am �005;36:55-61

�) Harman MK, Markovich GD, Banks SA, Hodge SA. Wear patterns on tibial plateau from valgus and varus osteoarthritic knees. Clin Orthop 1998; 5� : 1� 9-58.

5) King J, Daniel L, Stamper PA-C, Douglas CS. Minimally Invasive Total knee arthroplasty compared with traditional total knee arthroplasty. JBJS �007; 89A: 1�97-1503.

6) Dalury DF, Dennis DA. Mini-incision total knee arthroplasty can increase risk of component malalignment. Clin Orthop �005; ��0: 77-81.

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1�) Ko PS, Tio MK, Tang YK, Tsang WL, Lam JJ. Sealing the intramedullary femoral canal with autologous bone plug in total knee arthroplasty. J Arthroplasty �003; 18: 6-9.

13) Hiippala ST, Strid SJ, Wennerstrand MI, Arvela JV, Niemela HM, Mantyla SK, Kuisma RP, Ylinen JE. Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg 1997; 8�: 839-��.

1�) Álvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion �008, �8: 519-�5.

15) Vertullo CJ, Davey JR.The effect of a tibial baseplate undersurface peripheral lip on cement penetration in total knee arthroplasty. J Arthroplasty �001; 16: �87-�9�.

16) Pittmann G, Peters C, Hines JL, Bachus KN. Mechanical bond strength of the cement – tibial component interface in total knee arthroplasty. J Artroplasty �006; �1: 883.

17) Müller RT, Schürmann N. Shear strength of the cement metal interface – an experimental study. Arch Orthop Trauma Surg 1999; 119:133–138 .

18) Iesaka K, Jaffe WL, Jones CM, Kummer FJ. The effects of fluid penetration and interfacial porosity on the fixation of cemented femoral components. JBJS �005; 87B: 1�98-130�.

19) Miller J, Johnson A. Advances in cementing techniques in total hip arthroplasty. Stillwell WT (editor). The art of total hip. arthroplasty. Grune & Stratton 1987: �77-�9�.

�0) Maistrelli GL, Antonelli L, Fornasier V, Mahomed N. Cement penetration with pulsed lavage versus syringe irrigation in total knee. Clin Orthop 1995; 31�: �61.

�1) Springer BD, Scott RD, Thornhill TS. Conversion of failed unicompartmentel knee arthroplasty to TKA. Clin Orthop �006; ��6: �1�-�0.

��) Parvizi J, Saleh KJ, Kayland PS, Pour AE, Mont MA. Efficacy of antibiotic-impregnated cement in total hip replacement. A metaanalysis. Acta Ortop Scand �008; 79: 3�7-33�.

�3) Dall GF, Simpson PMS, Mackenzie SP, Breusch SJ. Inter- and intra-batch variability in the handling characteristics and viscosity of commonly used antibiotic-loaded bone cements. Acta Orthop Scand; �007: 78: �1�-�.

��) Flivik G, Yuan X, Ryd L, Juliusson R, Lidgren L. Effects of lamination on the strength of bone cement. Acta Orthop Scand 1997; 68: 55-68.

�5) Saha S, Pal S. Mechanical properties of bone cement: A review. J. Biomed Mater Res 198�; 18: �35-�6�.

�6) Walker PS, Soudry M, Ewald FC et al. Control of cement penetration in total knee arthroplasty. Clin Orthop 198�; 185: 155.

�7) Noble PC, Conditt MA, Thompson MT, Stein JA, Kreuzer S, Parsley BS, Mathis KB. Extraarticular abrasive wear in cemented and cementless total knee arthroplasty. Clin Orthop �003; �16: 1�0-1�8.

�8) Keene GCR, Jeer PJS. Cement retrieval in minimally invasive knee surgery. The 90° ball probe. J Arthroplasty �005; �0: 798-99.

�9. Crowningshield RD, Wimmer MA, Jacobs JJ, Rosenbery AG. Clinical performance of contemporary tibial polyethylene components. J Artroplasty �006; �1: 75�-761.

30) Niki Y, Matsumoto H, Matsumoto H, Otani T, Tomatsu T. Toyama Y. How much sterile saline should be used for efficient lavage during total knee arthroplasty? Effects of pulse lavage irrigation on removal of bone and cement debris. J Artroplasty �007; ��: 95-99.

31) Bert J, McShane DJ. Is it necessasary to cement the tibial stem in knee arthroplasty. Clin Orthop 1998; 358: 73-78.

3�) Peters CL, Craig MA, Mohr RA, Bachus KN. Tibial component fixation with cement. Clin Orthop �003; �09: 158-168.

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Refobacin is a licensed trademark from Merck KGaA

Professor Lars Lidgren - MD, PhD - University Hospital in Lund, Sweden Head of Department of Orthopaedics

Professor Urban Rydholm - MD, PhD - University Hospital in Lund, Sweden

Associate Professor Kaj Knutson - MD, PhD - University Hospital in Lund, Sweden

Otto Robertsson - MD, PhD - University Hospital Reykjavik, Iceland

Dr Pietro Randelli – MD- University of Milan, Italy - Policlinico San Donato, Milanese, Italy

This educational material is developed and produced by Biomet in cooperation with:

Poul Torben Nielsen– Clinical Director of Hip and Knee Surgery Orthopaedic Division,

North Denmark Region and Aalborg University Hospital – Denmark

Reviewed and endorsed by:

This brochure is presented to demonstrate the Modern Cementing Technique - Knee arthroplasty - utilized by Dr Poul Torben Nielsen.

Biomet Cementing Technologies, as manufacturer of products within the field of cement and cementing systems, does not practice medicine and does not recommend this or any other surgical technique, nor any particular orthopaedic implant, for use on a specific patient. The surgeon who performs any implant procedure is responsible for determining and utilizing the appropriate techniques for implanting the prosthesis in each individual patient. Biomet Cementing Technologies is not responsible for selection of the appropriate orthopaedic implant or surgical technique, nor does it advocate a particular technique to be utilized for an individual patient.

Biomet Cementing Technologies ABBox 46 · 275 21 Sjöbo

Tel: + 46 416 258 50 · Fax: +46 416 258 52www.biomet.com · www.bonecement.com

© 2009 Biomet Cementing Technologies AB

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