Debate in favour of uncemented total hip replacement

1. UNCEMENTED TOTAL HIP
REPLACEMENT
DR SABYASACHI BARDHAN
Consultant Trauma & Joint
Replacement Surgeon

2. INTRODUCTION
• THR is a very successful orthopaedic
procedure
• Total hip replacement development began
with cementless THR. McKee and Watson-
Farrar documented an early model of an
artificial hip joint between 1956 and
1960.[#]
• Charnley’s Low Friction Arthroplasty
emerged as GOLD STANDARD
# McKee GK, Watson-Farrar J. Replacement of arthritic hips by the McKee-Farrar
prosthesis. J Bone Joint Surg Br 1966;48: 245–59.

3. • Outcomes of other cemented THR procedures were
markedly poor
• Loosening occurred in 34% at 7.4 years after surgery
using the Charnley-Müller type ; 40% at 10 years after
surgery using the Müller type
• Cementless THR was developed in the late 1960s
• Smooth Surface: Poor outcome
• The development of material engineering during the 1980s
completely changed the condition because materials that
allow bone ingrowth became available.
Kawamoto K, Hasegawa Y, Iwase T, Iwasada S, Kanamono T, Iwata H. Failed cementless total hip
arthroplasty for osteoarthrosis due to hip dysplasia: a minimum fi ve-year follow-up study. Bull
Hosp Joint Dis 1998;57:130–5.

4. PRINCIPLE
• OSTEOINTEGRATION: bone ingrowth & ongrowth
• Implant design,
• Appropriate surface treatment,
• Primary mechanical stability, and
• Patient’s osteogenesis

5. Femoral Stems
• Mont Group Classification
a) Single Wedge
b) Double wedge metaphyseal
filling
c) Tapered
d) Cylindrical fully coated
e) Modular
f) Anatomic

6. Acetabular Cups
• 1st generation
• 2nd generation
• 3rd generation

7. WHY UNCEMENTED

8. ASEPTIC LOOSENING
• Commonest cause of failure (51.9%) [Int Orthop.
2008 Oct; 32(5): 597–604.Published online 2007
Apr 19]

9. CEMENTATION
• Exacting process
• Difficult to master
• Variability
Steep learning Curve- needs 4 months to train a junior
– BOA Seminar 2010
FEMORAL CEMENTING TECHNIQUES: CURRENT TRENDS IN THE UK
Ann R Coll Surg Engl 2006; 88: 127–130
However, inconsistencies in the time-dependent material properties of cement remain a
cause of concern. Uncontrolled and inconsistent temperature is an important
contributing factor.

10. Caton J, Papin P. Total Hip Arthroplasty in France Typologie
et épidémiologie des prothèses totales de hanche en
France. e-mémoires de l’Académie Nationale de Chirurgie.
2012;11:1–7.
It is recommended nowadays not to use a cemented titanium stem
because it can generate tremendous amount of Ti debris once
loosened, and to use proximally or fully hydroxyapatite-coated
cementless titanium stem
Ollivere B, Wimhurst JA, Clark IM, Donell ST. Current
concepts in osteolysis.
J Bone Joint Surg Br.
2012;94:10–15
low dose of ultra-high molecular weight polyethylene
(UHMWPE) or PMMA particles (0.63 mg/mL) displayed strong
alkaline phosphatase activity

11. J Orthop Res. 2011 May;29(5):781-6. doi: 10.1002/jor.21287. Epub
2010 Dec 7.
Polymethylmethacrylate and titanium alloy particles
activate peripheral monocytes during periprosthetic
inflammation and osteolysis.
Yang SY1, Zhang K, Bai L, Song Z, Yu H, McQueen DA, Wooley PH
PMMA readily activate peripheral monocytes and promote
the cell trafficking to the debris-containing prosthetic
tissues.
Acta Orthop 2005; 76: 375 – 385.
Hydroxyapatite coating of the prosthesis may prevent
osteolysis following injection of intra-articular particles
by sealing the implant-bone interface from their
ingression though the promotion of osseointegration at
this interface

12. MORTALITY
Donaldson ;British Journal Anaesth 2009
Recommends avoid cemented implants in elderly /IHD /COPD
Scandinavian Journal of Surgery 102: 124–128, 2013 T. Yli-Kyyny et al
perioperative cardiovascular disturbances occur when modular cemented stems are
used in hip fracture patients

13. JBJS.Br 1987 Jan 69(1): 45-55

14. Uncemented proximally coated stems showed
significant better long term survivorship than its cemented counterpart
Cemented Versus Cementless Stems: A Verdict Is In
Robert B. Bourne, MD, FRCSC; Kristoff Corten, MD
Orthopedics September 2010 - Volume 33 · Issue 9
SURVIVORSHIP

15. SURVIVORSHIP
New Zealand Joint Registry 13 yrs FU : Kaplan-
Meier survival curve –
Uncemented long term survival was better in young and
those over 70 yrs

16. SURVIVORSHIP

17. Orthopedic Reviews 2013; volume 5:e8: Cemented versus uncemented
fixation in total hip replacement: a systematic review and meta-analysis
of randomized controlled trials :Ali Abdulkarim, et al
SURVIVORSHIP

18. Aseptic loosening of the acetabular component in relation to the positioning of
prosthesis
Shishir Rastogi, V Trikha, S Bhan, C Bal
All India Institute of Medical Sciences, New Delhi, India
Forty-eight patients having 64 cemented or cementless total hip arthroplasties were followed
up. The follow up period ranged from 18 to 120 months (mean 37 months). The overall
clinical outcome was better in cementless than in cemented prostheses.
SURVIVORSHIP
Factors affecting aseptic loosening of 4750 total hip arthroplasties:
multivariate survival analysis
BMC Musculoskeletal Disorders20078:69
cemented cups and stems have a higher risk of failure compared with
uncemented

19. PERIPROSTHETIC FRACTURE
We found a high incidence of early PPF associated
with the CPT stem in this old and frail patient group. A
possible explanation may be that the polished tapered stem acts
as a wedge, splitting the femur after a direct hip contusion.

20. The postoperative fracture prevalence for cemented primary
arthroplasties was 0.6% of the 17,579 cemented primary arthroplasties and
0.4% of the 2,078 uncemented primary arthroplasties
2.8% of fractures occurring in the 3,265 cemented revision cases and 1.5% of the
1,132 uncemented revision cases

21. PERIPROSTHETIC FRACTURE
B2 loose stem; good bone o Fixation alone will not work
o Revise the femoral component ,+/- strut allograft, +/- plates
o Best results seen with patients revised with uncemented,
extensively porous coated femoral stems
o May also consider use modular, fluted taper stems § Need good quality
intact diaphyseal bone to engage the taper.
§ The more proximal the intact diaphysis the better
§ Consider placing a cerclage around intact bone
Periprosthetic Fractures Around THA – When/How to fix, When to Revise
Boot Camp 2013
Phoenix, AZ
ota.org/media/80921/14-Horwitz-Periprosthetic-Fx.pdf

22. Geriatr Orthop Surg Rehabil. 2012 Sep; 3(3): 107–120.
doi: 10.1177/2151458512462870
A Review of Periprosthetic Femoral Fractures Associated With Total Hip
Arthroplasty
Daniel Marsland, MRCS, MSc (SEM)1 and Simon C. Mears, MD, PhD
Revision of a loose stem has traditionally been performed with a long-stem
cemented prosthesis, although complication rates can be high.
only 60% of patients had a stable implant with fracture union.
PERIPROSTHETIC FRACTURE

24. CONCLUSION
• Growing popularity and acceptance
• Survivorship: comparable in elderly, better for young
patients
• Easier to master
• Shorter surgery
• Safer than cemented hip
• Better results in periprosthetic fractures

25. THANK
YOU