3.7
Properties of Bone Cement:
Which Cement Should We Choose
for Primary THA?
Ove Furnes, Leif Ivar Havelin, Birgitte Espehaug
Summary
In total hip arthroplasty (THA), the surgeon should use a
well-proven antibiotic-containing cement, like Palacos or
Simplex. In addition to antibiotics in the cement, systemic
antibiotic prophylaxis should be administered 4 times on
the operating day to prevent septic implant loosening.
Studies based on data in the Norwegian Arthroplasty
Register indicate that the type of cement may be a more
important predictor for prosthesis outcome than commonly used prosthesis brands.
Introduction
In the early phases of hip replacement, surgery focus was
on the design of the femoral stem, and on bearing surfaces. There was less focus on different types of bone cement. Later, when aseptic loosening became a recognised
problem and the term »bone cement disease« was introduced, there was a shift towards more use of uncemented
implants and towards new cements like the cold curing
Boneloc cement and different low viscosity cements. The
Swedish and Norwegian hip implant registers have shown
that the type of cement is important for the performance
of the hip implant and type of cement may in many ways
be more important than the design of the prosthesis. The
Norwegian hip implant register has published several
reports concerning bone cement.
Results of Bone Cement Studies
in the Norwegian Arthroplasty Register
In our first study on bone cement and prosthesis failure
in Charnley prostheses, the cold curing cement Boneloc
performed inferior to high viscosity cements, and low
viscosity cements performed worse than high viscosity
cements [5] (⊡ Fig. 3.66). CMWIII was the most widely
used low viscosity cement and hence the evidence against
this cement was strongest. The poor performance of low
viscosity cements might in part be explained by the difficult handling characteristic of these cements. In the next
study from 1997 we showed that the polished tapered
Exeter stem performed better with use of Boneloc cement
than did the Charnley stem [4]. This is an interesting
perspective and it seems that different prosthesis designs
might require different mechanical properties of the cement. A 10-year follow-up of the different cement brands
used in Norway showed that the high viscosity cement
CMWI performed poorer than the other high viscosity cements Palacos and Simplex [3]. The poor performance of
the CMWIII cement was further confirmed. A Charnley
prosthesis implanted with CMWI cement had a failure rate
of 12% at 10 years, but only 5.9% when used with gentamicin-containing Palacos cement (⊡ Fig. 3.67). If you as a
surgeon implant 100 Charnley prostheses with CMWI cement, this will lead to 6 extra revisions after 10 years compared to using Palacos or Simplex cement. These findings
represent an argument for greater awareness regarding
current marketing regulations of medical devices.
Should We Add Antibiotic in the Cement?
In two publications we have addressed the question of
whether to use antibiotics in the cement or not, and the influence of systemic antibiotic prophylaxis. We have shown
that use of systemic antibiotic prophylaxis gave less aseptic
and septic loosening of the implant, and that the addition
of antibiotic in the cement gave an added protective effect
[2] (⊡ Fig. 3.68). A combination of systemic antibiotic and
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Part II · Basic Science
antibiotic in the cement gave four times less septic revisions
and two times less aseptic revisions compared to use of systemic antibiotic prophylaxis only. It seems to be important
to have high doses of antibiotics locally in the joint to prevent the bacteria to colonise the implant. In a recent study
with over 10-years follow-up, the performance of the antibiotic loaded bone cements was still good and the protective effect of systemic antibiotic prophylaxis combined with
antibiotic in the cement was maintained both for aseptic
and septic loosening. The study implies that the concern of
3
(%)
100
HIGH VISCOSITY
98
NOT REVISED
96
LOW VISCOSITY
94
92
⊡ Fig. 3.66. Kaplan Meier survival curves
of Charnley femoral prostheses with
high viscosity, low viscosity, and Boneloc
cement. (Reproduced with permission
from [5])
90
BONELOC
p<0.0001
0
1
2
⊡ Fig. 3.67. Survival curves calculated
for 17,323 Charnley THRs with type of
cement as the strata factor and any
failure of either component as the
endpoint (817 failures). The Cox proportional hazards method was used for
adjusted estimates. (Reproduced with
permission
from [3])
Prosthesis survival (%)
100
3
4
YEARS
5
6
7
Adjusted
95
90
Palacos with
gentamycin
Palacos
Simplex
CMW1 with
gentamycin
CMW1
CMW3
85
80
0
2
4
6 8 10 12
Years to failure
F(10) RR
PalacosG5.9
1ref
Palacos 6.6
1.1
Simplex 7.1
1.1
p
CMW1G
CMW1 12.0
2.1
2.0
<0.001
<0.001
CMW3 17.0
3.0
<0.001
105
Chapter 3.7 · Properties of Bone Cement: Which Cement Should We Choose for Primary THA?
Percent not revised
a bio-mechanically weaker bone cement due to added antibiotics does not have any clinical significance, at least not
within 10 years [1]. We have further shown that giving four
doses antibiotics systemically the operating day resulted in
less revisions due to septic and aseptic loosening compared
to one, two or three doses, and that there was no additional
beneficiary effect of giving the antibiotic prophylaxis for
two or three days (⊡ Fig. 3.69). Most Norwegian surgeons
gave either penicillin (Oxacillin, Dikloxacillin) or first and
second generation Cephalosporin’s in doses of 2 g × 4.
100
%
Antibiotics adm inistered:
98
Systemically and
in cement
Systemically
only
96
No antibiotics
In cement only
94
p=0.001
92
⊡ Fig. 3.68. Cox regression-adjusted
90
0
2
4
6
Years postoperatively
100
%
Percent not revised
13
8
3
2
12
10
survival curves calculated with revision
due to any cause as the endpoint and
regimen as the strata factor. (Reproduced with permission from [2])
14
95
11
⊡ Fig. 3.69. Cox regression-adjusted
90
0
2
4
6
8
10
12
Years postoperatively
14
16
survival curves with aseptic loosening as
endpoint for THAs receiving antibiotic in
the cement and antibiotic prophylaxis
systemically for 1 day [with number
of doses as subscript-i.e., 1 dose (11), 2
doses (12), 3 doses (13) and 4 dose (14)],
2 days (2) and 3 days (3)
3
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Part II · Basic Science
Take Home Messages
I
I
▬ The cement type may be a more important predictor for long term outcome than commonly used
prosthesis brands.
▬ Palacos and Simplex cements are associated with
the lowest risk for revision.
▬ The risk for infection following primary THA is
lowest when antibiotic loaded cement is used in
combination with 4 systemic antibiotic doses on
the operating day.
3
Acknowledgements. We thank orthopaedic surgeons at
all hospitals in Norway without whose co-operation the
Norwegian Arthroplasty Register would not be possible.
The work of the register is a teamwork and we thank our
co-authors Lars B. Engesæter, Stein Emil Vollset, Stein
Atle Lie and Norvald Langeland, and our secretaries
Adriana Opazo, Ingvan Vindenes and Inger Skar for their
accurate registration.
References
1.
2.
3.
4.
5.
Engesæter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI.
Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision
rate of 22,170 primary hip replacements followed 0–14 years in
the Norwegian Arthroplasty Register. Acta Orthop Scand. 2003;
74:644–651
Espehaug B, Engesæter LB, Vollset SE, Havelin LI, Langeland N. Antibiotic prophylaxis in total hip arthroplasty. Review of 10,905
primary cemented total hip replacements reported to the Norwegian Arthroplasty Register, 1987–1995. J Bone Joint Surg (Br) 1997;
79B:590–595
Espehaug B, Furnes O, Havelin LI, Engesæter LB, Vollset SE. The
type of cement and failure of total hip replacements. J Bone Joint
Surg (Br) 2002; 84-B: 832–838
Furnes O, Lie SA, Havelin LI, Vollset SE, Engesæter LB. Exeter
and Charnley arthroplasties with Boneloc or high viscosity
cement. Comparison of 1127 arthroplasties followed for 5 years
in the Norwegian Arthroplasty Register. Acta Orthop Scand 1997;
68:515–520
Havelin LI, Espehaug B, Vollset SE, Engesaeter LB. The effect of
cement type on early revision of Charnley total hip prostheses.
A review of 8,579 primary arthroplasties from the Norwegian
Arthroplasty Register. J Bone Joint Surg (Am) 1995; 77A:1543–
1550.