Learn the basics of good cementing during a total hip replacement.

1. Fun with the Gun! – Workshop
on Cementing technique
Dr Vaibhav Bagaria
MBBS, MS, FCPS
Origyn Health Care, Nagpur & Delhi
CARE Hospital, Nagpur

2. Cementing Synopsis







Cement Basics
Bone bed preparation - Clean bone bed
Mixing & Delivery
Pressurization - Good cement filling
Safe working environment
Expecting unexpected & dealing with it!
Cement – Other uses

3. Good Cementing Triangle

4. Cement - Basics



Two primary component – PMMA
powder and a liquid monomer – MMA.
Mixed in ratio of 2 :1 to form PMMA
cement.
To make it radioopaque: zirconium
dioxide (ZrO2) or barium sulphate
(BaSO4)

5. Contents
Powder
(pouch)
Polymer
Content
Content
PMMA
Liquid
(Ampoule)
Monomer
Starter
BPO
Initiator
DmpT
MMA
Radiopacifi ZrO2/BaSO4 Inhibitor
er
HQ
Antibiotic
Chlorophyll
Colouring
Agent

6. Process of Polymerization




Four Phases: Mixing, Pickup, working and
Final set.
Important Factors – temperature, humidity,
type of mixing and type of cement.
Manual handling of the cement and body
temperature will reduce the final setting time.
Variation in setting time over the cement’s
shelf life can be minimized by storing the
cement under the recommended conditions.

7. Different Types


Low viscosity: Long-lasting liquid, or mixing
phase, which makes for a short working
phase. Requires strict adherence to
application times but gives time for filling
Delivery syringe
High viscosity: Short mixing phase, loose
their stickiness quickly. Longer working
phase, giving the surgeon more time for
application.

8. Commercially available
preparations





CMW1, 2, 3: Depuy Inc
Palacos: Heraeus Medical GmbH
Simplex: Stryker
Cobalt GV, HV Biomet cement:
Biomet
Smart Set: Depuy

10. Different Types

11. Bone Bed Preparation



Effective micro-interlock between the
bone - cement is essential.
Use of Pressure Pulse lavage and
brush have shown to reduce the
incidence of aseptic loosening.
Curettes, knives can be used but not as
effective.

12. Bone Bed Preparation







Reaming
Brushing
Lavage
Cement Restrictor
Anchorage hole
Key – To preserve the cancellous bone.
Aim – Good microlock

13. Reaming




Shape the femoral canal and acetabular
cavity for even cement mantle.
Preoperative planning helps.
Preserve the cancellous bone.
Preserve the transverse acetabular
ligament.

14. Pre Operative Plan
Acetabular Reaming
Femoral Reaming

15. Brushing and lavage



Brushing – both acetabular and femoral
reduce the loose cancellous bone and
soft tissue.
High pressure pulse lavage produce
clean surface. Also prevents circulatory
changes.
Both reduce the risk of lamination in the
cement that can decrease the strength
of mantle by 8 -16%

16. Brushing and Lavage
Brushing
Pulse lavaging Canal

17. Cement Restrictor/Anchorage
holes
For good filling and
pressurization; Reabsorbable plugs
also available
5 -8; Improve fixation;
Drilled or Impacted

18. Mixing





Entire liquid to polymer powder.
Initial 30 sec – insufficient liquid.
Hairy strands, glistening liquid.
Strands no longer form, shine disappear,
soft dough like consistency, can be
scarped – beginning of working phase.
Vaccum Mixing -prevents air entrapment
in cement, reduces cement porosity,
unbounded particles - strength!

19. Vacuum Mixing

20. Delivery




Hand packing – made into rough
cylindrical mass and then packed.
Gun: ensures delivery under pressure.
Inject the cement in retrograde fashion,
letting the cement gun work its own way
out of the femur.
Swedish Hip Registry has shown that
retrograde cement filling using a
cement gun in the femur reduces risk of
revision.

21. Cement Gun

22. Pressurization




Involves use of Cement Gun, special
pressurizers, and centralizers.
Afford greater penetration into
cancellous bone ensuring micro – lock.
Optimal viscosity is key to good
pressurizing.
Femur -Marrow extrusion in the greater
trochanter (the so-called sweating
trochanter sign).

23. Pressurization

24. Pressurization-technique

25. Cement Other uses
Knee Spacer
Hip Spacer
Tumor Cases
Antibiotic Beads

26. Safety First!




Liquid monomer is highly volatile,
flammable, powerful lipid solvent.
Avoid contact of the liquid with surgical
gloves, skin or mucous membranes.
Fumes -irritation of the respiratory tract,
eyes, liver; hypersensitivity, contact
dermatitis.
Contact Lenses: reactions between
monomer vapors and soft contact
lenses.

27. Word of Caution!



Premature insertion of bone cement ->
drop in BP, arrhythmias or ischemia.
Expulsion of bone marrow –PE; esp
Osteoporotic, NF # &
overpressurization.
Inform Anaesthetist prior to cementing –
Hypotensive episode lasts between 30
sec to 5 min.

28. Expecting the unexpected
“You can handle anything if you think
you can. Just keep your cool and your
sense of humor."
Smiley Blanton

29. Work Shop



8 stations – 4 cement guns, 4 hand
packing.
Both hand mixing and use of gun.
Allocate jobs – mixing, insertion of
cement restrictor, cement delivery,
pressurization.