Ersin

KÜRŞAT
December
 Contents
 History
 Fields of applications
 Components
 Polymerisations
 Clinical case
 Antibiotics
 Clinical studies
 Surgical procedurs
 HISTORY
 The story of modern cements began
with Otto Röhm’s invention in the
early 20th century of polymethyl
methacrylate (PMMA), a solid
material with good biocompatibility.
 In the 1960s Sir John Charnley began
using bone cement on numerous
patients for the fixation of both the
femur and acetabulum. Before the
end of the decade, Buchholz came up
with the idea of adding an antibiotic
to the cement to decrease the
incidence of infection.
 The evolution of bone cement
        First synthesis of PMMA by O. Röhm
1902        
      First industrial production of PMMA
1936
Animal studies on skull defects
1939
Human studies on skull defects
1940
Polymerisation of PMMA becomes possible at room
1943 temperature

1949 Judet brothers developed hip implant with PMMA

1955 Filling of spinal defects (Idelberger)

1959 Sir John Charnley uses PMMA cement in hip replacement;

femur and acetabulum implant is fixed by bone cement
1970
Buchholz used PMMA bone cement with gentamicin; E.
~1990 Merck starts marketing bone cement.

2000 Focus on cementing technique in trade publications

 Bone Cement
 Bone cements consist of two primary
components: a powder consisting of
copolymers based on the substance
polymethyl methacrylate (PMMA),
and a liquid monomer,
methylmethacrylate (MMA). These
two components are mixed at an
approximate ratio of 2:1 to form a
polymethyl methacrylate cement.
 When the polymer powder and
monomer liquid meet, the
polymerization process starts. During
polymerization of the monomer, the
original polymer beads of the powder
are bonded into a dough-like mass.
The mass hardens approximately 7-
15 minutes after the start of mixing,
depending on temperature
 The polymerisation process can be
divided into four different phases:
Processing times of bone
cement
 Polymerization depends on
 a.Room temperature

 b.Temperature of the bone cement

components
 c.Prothesis temperature

 1. Mixing phase
 Complete wetting of the powder

with liquid !
 This produces a homogeneous
 2. Waiting phase
 Swelling of the paste material

 Slow polymerisation

 Increased viscosity, but paste still

sticky
 3. Working phase
 completion of the waiting phase
essential!(ideal working viscosity)
 application into the femur(for manual

application non-sticky,viscosity not too

high))
 4.Hardening phase
 Strength of the cement increases

 Polymerisation comes to a halt

 Duration of poşymerisation
dependent on
.Room temperature,
.Component temperature,
.Prothesis temperature
.Air humidity
 Properties
 During polymerization, cement
properties critical for operating
procedures, such as viscosity
change, setting time, cement
temperature, mechanical strength,
shrinkage and residual monomer, are
determined. These properties will
influence cement handling,
penetration and interaction with the
prosthesis.
 Viscosity
 Mixing together the powder and the
liquid components marks the start of
the polymerization process.
 During the reaction, the cement
viscosity increases, slowly at first,
then later more rapidly.
 Clinical experience has shown that
high viscosity cements produce
better clinical results, as compared
to low viscosity cements.
 Viscosity affects
the following:

Mixing behaviour
 Penetration into

cancellous bone
 Resistance

against bleeding
 Insertion of the

*Boneimplant
cements may be divided into two
kinds: low viscosity and high viscosity.
 Low viscosity: These cements have a
long-lasting liquid, or mixing phase, which
makes for a short working phase.4 As a
consequence, application of low viscosity
cements requires strict adherence to
application times.
 High viscosity: These cements have a
short mixing phase and loose their
stickiness quickly. This makes for a longer
working phase, giving the surgeon more
time for application
 Revision due to stem loosening

•The Norwegian Arthroplasty Register

shows that high viscosity bone cements
yield better long-term results than low
 Temperatures
 Temperature affects mixing time, delivery
of the cement, prosthesis insertion, and
other aspects of the cementing process. It
is therefore very important to control the
temperature of the bone cement and the
OR.
 To achieve optimal cement properties, it is
important to adhere to the time schedules
indicating the correlation of temperature to
handling time. These time schedules are
usually included in the instructions for the
bone cement.
 High viscosity cements are sometimes pre-
chilled for use with mixing systems for
easier mixing and prolonged working
 Mechanical properties
 The bone cement is subjected to high
mechanical stress in the body. In vivo, the
biomechanical situation is rather complex,
involving different types of loading
(bending, compression, shear), which must
be tested. The international standard ISO
5833 describes the methods for
determining compressive strength,
bending strength and bending modulus.7
 As the cemented implant is subjected to
not only static load but also dynamically
 Antibiotic-loaded bone
cement
 Periprosthetic infection is the most feared
complication in total hip and knee
replacement. The infection usually leads to
a complete failure of the joint
replacement, resulting in a long series of
operative procedures, great discomfort for
the patient and heavy costs.1
 Infections occur because of the high
affinity of many germs to the surface of
implants. Once settled, germs are less
sensitive to antibiotics, as they are
covered with a “slime” preventing them
 A solution to the problem is preventing the
settlement of germs. The use of antibiotic-
loaded bone cements allows for high local
concentrations of antibiotics to be
administered to the areas surrounding the
implant, protecting the implant from the
settling of germs. Moreover, antibiotic
levels in the serum are sufficiently low so
as to avoid causing side effects.
 The addition of antibiotics to bone
cement was undertaken at the
beginning of the 1970s by
Buchholz,2 from the Endo-Klinik in
Hamburg. His idea was to add
antibiotics to the cement in order to
reduce the incidence of infection,
which was high at that time. Using
gentamicin in combination
with PMMA cement, it was found that
the combination with gentamicin was
 Attention must be given to reducing the
incidence of infection in joint replacement
surgery and to fighting infection once it
has occurred.
 Orthopaedic infections
 There are numerous reports in the
literature about the incidence of
postoperative wound sepsis and the
organisms causing this complication.
Almost 75% of all bacteria that can be
isolated during hip operations are Gram-
positive, with staphylococci representing
the majority. Among Gram-negative
 Antibiotic therapy,
although usually not
adequate alone, is a
critical element in the
treatment of infected
total hip arthroplasty.
Consultation with an
infectious disease
specialist can help
the surgeon select
the appropriate
antibiotic, determine
the duration of
therapy, and evaluate
 Antibiotic therapy, although usually
not adequate alone, is a critical
element in the treatment of infected
total hip arthroplasty. Consultation
with an infectious disease specialist
can help the surgeon select the
appropriate antibiotic, determine the
duration of therapy, and evaluate the
response to the treatment
 Antibiotic-loaded bone
cement
 Gentamicin is an aminoglycoside
antibiotic . It is bactericidal, has a
dose-dependent killing curve,
remains stable when exposed to heat
and is soluble in water. These four
characteristics make it especially
suited for use in bone cement.
 Gentamicin loaded
bone cement
 Gentamicin is mixed in bone cement for
prophylaxis against infections after
arthroplasties. The substance is slowly
eluted in the surrounding tissue
 Clindamycin belongs to the group of
lincosamide antibiotics. It is additionally
active against some anaerobic germs,
such as peptostreptococci, anaerobic
germs. This activity makes it a suitable
antibiotic in combination with gentamicin,
covering most of the germs typically
occuring in periprosthetic infection
 Gentamicin and clindamycin is a
combination known to have a bacterical
effect on more than 90% of the bacteria
common to infected arthroplasty cases.8
 Vacuum Mixing and
Delivery
 Vacuum mixing, which was adapted from
the dental field, was developed for bone
cement in the early 1980s. Vacuum mixing
has several important purposes:
 to enhance cement properties
 to reduce bone cement porosity and
 to improve the working environment in the
operating room.
 Numerous studies have shown that,
compared to hand mixing, vacuum mixing
prevents air entrapment in cement,
reduces cement porosity, decreases the
number of unbounded particles in cement
and increases cement’s mechanical
strength. Vacuum mixing furthermore
reduces monomer evaporation and
exposure in the operating room
 Mixing as well as
collecting cement
under vacuum
yields a
homogenous mix
without affecting
viscosity or any
cement additives
such as antibiotics
or radio-contrast
media.
 Delivering cement
with a
syringe,under
 Bone bed preparation and Pressurization in
Total Hip Replacement

 Careful preparation of the bone cavity and bone

bed with high-pressure pulse lavage and brushing
is essential for achieving an effective micro-
interlock between the bone and the cement.
 Clinical studies have shown that the use of high-
pressure pulse lavage reduces the risk of revision
due to aseptic loosening.
 In the early days syringes and knives were used
to clean the bone bed. These tools had the
disadvantage of removing healthy tissue along
with unhealthy and not sufficiently cleaning the
bone bed.
 The importance of careful preparation of
the bone surfaces, using brushes and
pulse lavage to achieve micro-interlock,
has been described since the 1970s.
 In the 1980´s techniques for pressurization
of bone cement were introduced. Proper
pressurization is important. The pressure
on the cement has to be larger than the
blood pressure no to be pushed out of the
bone. Pressure should be applied until the
viscosity of the bone cement has
increased so it is high enough to resist
 Reaming
 The bone cavity
should be shaped to
provide an even
cement layer between
the bone and
prosthesis. An even
cement layer provides
better stress
distribution and
reduces the risk of
cement mantle failure.
Size of reaming should
be determined at
preoperative planning.
 Brushing
 Mechanical
cleaning with a
brush is
recommended.
Accidental
introduction of
blood and tissue
debris into the
cement may cause
laminations, which
can lower the
effective strength
of the bone cement
by 8-
 Pulse Lavage
 Using high-
pressure pulse
lavage to remove
remaining bone
particles and
debris in a joint
arthroplasty
produces a clean
surface.
The risk of blood
lamination is
reduced and the
mechanical
strength of the
cement is
increased. The
 Bed Preparation
 A study concludes that
meticulous high volume,
high pressure pulsative
lavage reduces both
pulmonary physiological
derangements and fat
emboli.
 It was concluded that
the use of high volume
pressurized jet-lavage
for cleaning of the
intramedullary cavity
prior to cement
application in THR
 Anchorage holes and

restrictors
Anchorage holes in
the acetabulum
 The anchorage holes
are made in order to
remove as little bone as
possible and they may
be drilled and/or
impacted.
 Number of anchorage
holes drilled is
dependant on the
surgeon, but normally
5-8 holes are used.
 Anchorage holes
 Cement restrictors in the
femur
 In order to achieve good
filling and pressurization
in hip and knee
arthroplasties a cement
restrictor may be used to
plug the shaft. The plug
may also prevent the
passage of blood and air
prevent debris from
entering the femoral canal
and reduce bone cement
implant
syndrome.Resorbable
 Funcion of bone cement
 Fixing the artificial joint
 Anchoring the implant the bone
 Connection stabilisation of vertebral
defects
 Transfering load from the prothesis
to the bone
 Optimal load distribution
 Release of antibiotics
 All currently available bone cements are
base on MethylMethAcrylate (MMA) /
ButhylMethAcrylate / Styrene

 All cements consist of two components,

 i.e. Powder and liquid

 Yet there are significant differences in:

 Specification of monomers and polymers

 Composition

 Sterilization method

 Radiopaque additives

 Antibiotics and very important Manifacturing

process
Polymerisation Temperature of
Bone Cement
 Per mole MMA, during the radcal
polymerisation of MMA to PMMA, a
reaction enthalpy of 57 kj is released.
 Polymerization is an
exothermic reaction-cement
heat up while hardening.
 In vivo
 Palacos: 47oC(116oF)
 Reasons for a lower temperature
in vivo:
 Thin layer of cement(3-5 mm)
 Blood circulation dissipates the heat
 Heat uptake by the prosrhesis
 Heat uptake by vital tissue
 In vitro
 ISO requirement: maximum 90oC
(194oC)
 Palacos:70oC (158oF)
 Simplex: 90oC (194oF)