import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Anterior and lateral cortex during broaching and reaming **Protection**: Gentle broaching technique, feel for cortical contact, use image intensifier if canal anatomy unclear **Injury Risk**: Perforation leads to cement extravasation, loss of pressurization, thin or absent cement mantle **Location**: Posteromedial proximal femur, base of femoral neck **Protection**: Careful box chisel use, avoid aggressive medial impaction, controlled broaching **Injury Risk**: Calcar fracture compromises proximal cement mantle and stem stability **Location**: Lateral attachment of abductor muscles, vulnerable during exposure and cementing **Protection**: Careful soft tissue elevation, avoid excessive retraction, gentle stem insertion **Injury Risk**: Trochanteric fracture or avulsion leads to abductor dysfunction, Trendelenburg gait **Location**: Posterior to acetabulum, 1-2cm posterior to hip joint in posterior approach **Protection**: Mark nerve location, careful retractor placement, remove posterior extruded cement **Injury Risk**: Direct injury from retractors, compression from cement extrusion or hematoma **Location**: Systemic - pulmonary and cardiac circulation **Protection**: Communicate with anesthesia before cementing, adequate lavage, gentle pressurization, fluid loading **Injury Risk**: Bone cement implantation syndrome (BCIS) - fat/cement/marrow emboli causing hypotension, arrhythmia, cardiac arrest (0.5-1 percent incidence) Modern cemented femoral fixation using third and fourth-generation cementing principles represents the gold standard for total hip replacement in specific patient populations. This technique, developed through decades of research and registry data analysis, has demonstrated exceptional long-term survival rates when meticulous attention is paid to each step of the cementing process. ## Historical Evolution **First-Generation Cementing (1960s-1970s)** - Finger packing of cement in antegrade fashion - No canal preparation or lavage - No cement restrictor or pressurization - No stem centralization - Results: 30-40 percent failure at 10 years **Second-Generation Cementing (1980s)** - Introduction of cement gun for insertion - Still antegrade technique - Basic canal lavage - Limited pressurization attempts - Results: 15-20 percent failure at 10 years **Third-Generation Cementing (1990s-2000s)** - Distal cement restrictor (essential innovation) - Pulsatile lavage of canal - Retrograde cement gun insertion - Systematic pressurization - Stem centralization - Results: 5-10 percent failure at 15 years **Fourth-Generation Cementing (2000s-present)** - All third-generation principles PLUS - Vacuum mixing of cement (reduces porosity) - Modern polished taper stem designs - Improved centralizers - Better cement formulations - Results: 95 percent survival at 15 years, 90 percent at 25 years ## Primary Indications **Age-Related** - Patients over 70-75 years (lower activity demands) - Life expectancy less than 20 years - Elderly with limited mobility **Bone Quality** - Osteoporotic bone (Singh index less than 3) - Dorr C femoral morphology (champagne flute, wide canal) - Poor cortical bone for press-fit fixation - Thin cortices unable to support uncemented stems **Acute Fracture** - Displaced femoral neck fractures requiring arthroplasty - Elderly patients (over 65 years) with subcapital fractures - Immediate full weight-bearing required **Medical Conditions** - Rheumatoid arthritis with bone quality compromise - Chronic renal disease with metabolic bone disease - Inflammatory arthropathies - Paget disease (in quiescent phase) **Salvage Situations** - Failed hemiarthroplasty conversion - Some revision scenarios with good proximal bone stock ## Contraindications **Absolute** - Young active patient (under 50-55 years with high activity) - Known allergy to cement components (extremely rare) - Active infection **Relative** - Very young age (under 40 years) - High activity level patients - Dorr A bone (dense bone better for uncemented) - Need for MRI surveillance (metal artifact less than cement artifact) - Concerns about cement debris and third-body wear ## Patient Assessment **Clinical Evaluation** - Age, activity level, life expectancy assessment - Bone quality evaluation (clinical risk factors for osteoporosis) - Medical comorbidities (cardiac risk for BCIS) - Previous hip surgery or fractures - Expected compliance with rehabilitation **Imaging Assessment** *Radiographic Templating* - AP pelvis and lateral hip radiographs - Template for stem size and position - Assess femoral canal dimensions and morphology - Measure offset and leg length discrepancy - Identify any canal deformities or prior hardware *CT Scanning (if needed)* - Severe deformity or prior fracture malunion - Retained hardware requiring removal - Unclear canal anatomy on plain films - Revision cases with bone loss **Bone Quality Assessment** *Dorr Classification (Femoral Morphology)* - Dorr A: Dense metaphyseal bone, narrow canal (better for uncemented) - Dorr B: Intermediate bone density and canal width (suitable for either) - Dorr C: Osteoporotic, wide champagne flute canal (IDEAL for cemented) *Singh Index (Trabecular Pattern)* - Grade 6-5: Normal trabeculae (may use uncemented) - Grade 4-3: Reduced trabeculae (consider cemented) - Grade 2-1: Severe osteoporosis (CEMENTED indicated) ## Equipment and Implants **Cemented Stem Options** *Composite Beam Stems (Force-Closed Fixation)* - Charnley stem (original, matt finish, broad mediolateral) - CPT stem (collarless polished taper) - Stanmore stem - Concept: Rough surface bonds to cement, stem-cement composite transfers load *Taper Slip Stems (Shape-Closed Fixation)* - Exeter stem (gold standard polished taper) - C-Stem (similar design) - Concept: Polished taper subsides minimally into cement, cement-bone interface critical **Cement Selection** - PMMA bone cement (polymethylmethacrylate) - Modern formulations: Palacos, Simplex, CMW - Antibiotic-loaded cement (optional in primary cases, standard in some regions) - Vacuum mixing system (reduces porosity 80-90 percent) **Specialized Cementing Equipment** *Essential Items* - Cement restrictor (flexible polyethylene or bone plug) - Cement gun with long flexible nozzle - Pressurizer (plug on handle for pressurization) - Pulsatile lavage system (minimum 1-liter capacity) - Femoral canal brushes (multiple sizes) - Stem centralizers (proximal and distal if using Exeter-type) *Optional but Recommended* - Vacuum mixing system for cement - Suction catheter for deep canal - Bone wax for hemostasis - Image intensifier (for difficult anatomy) ## Anesthetic Considerations **BCIS Prevention** - Discuss risk with anesthesiologist preoperatively - Fluid loading before cementing (500-1000mL crystalloid) - Arterial line for high-risk patients (ASA 3-4, age over 80) - Preparation for vasopressor support if needed **Monitoring** - Standard ASA monitors - Consider arterial line in elderly or cardiac patients - Communicate before cement insertion and stem impaction ## Patient Positioning and Draping **Positioning** (Approach-Dependent) - Lateral decubitus (posterior or anterolateral approach) - Supine (direct anterior or anterior approach) - Cemented technique independent of approach chosen **Positioning Pearls** - Ensure pelvis stable and perpendicular to floor - All bony prominences padded - Access to femur for delivery into wound - Adequate space for cement gun insertion ## Surgical Approach **Approach Selection** (Cementing Technique Identical) - Posterior (Moore/Southern): Most common in Australia - Anterolateral (Hardinge/modified Hardinge) - Direct anterior (Smith-Peterson) - Lateral (Kocher-Langenbeck variant) **Critical Point**: The cementing technique described is IDENTICAL regardless of approach. The key is adequate femoral exposure for canal preparation. ## Femoral Exposure and Neck Osteotomy **After Acetabular Component Insertion** - Complete acetabulum preparation first - Insert acetabular component (cemented or uncemented per plan) - Confirm acetabular component stable - Now begin femoral preparation **Femoral Neck Osteotomy** (if not done already) - Level: 1cm proximal to lesser trochanter - Angle: Neutral to slight valgus - Technique: Oscillating saw, protect soft tissues - Remove femoral head **Femoral Delivery** - Deliver proximal femur into wound - Posterior approach: External rotation and adduction - Anterolateral: Flexion, adduction, internal rotation - Anterior: Extension and external rotation - Goal: Good visualization of femoral canal entry ## Canal Entry and Initial Preparation **Entry Point Identification** - Locate piriformis fossa (standard entry) - Entry slightly lateral to apex (for valgus stem position) - Alternative: Greater trochanter entry (trochanteric stems) **Box Chisel Use** - Insert box chisel at entry point - Direct handle LATERALLY (valgus direction) - Why: Prevents varus stem malposition - Remove cancellous bone from proximal metaphysis - Open canal for broach insertion **Initial Cancellous Bone Removal** - Use curettes to remove loose cancellous bone - Goal: Create space for cement mantle - NOT trying to achieve press-fit (opposite of uncemented) ## Sequential Broaching **Broaching Technique for Cemented Stems** *Key Difference from Uncemented* - Uncemented: Broach to tight cortical contact (press-fit) - Cemented: Broach to SIZE, leave 2-3mm space for cement **Sequential Steps** 1. Start with smallest broach that engages canal 2. Broach in neutral to slight valgus alignment 3. Target 10-15 degrees anteversion 4. Advance broach to predetermined depth 5. Remove broach, assess canal 6. Sequentially upsize broaches **Endpoint Determination** - Broach has reasonable stability (not loose, not tight) - Appropriate size for patient anatomy - Space for 2-3mm circumferential cement mantle - Correct depth matches templated position **Common Broaching Errors** - Over-broaching: Leaves insufficient cement space, leads to thin mantle - Under-broaching: Poor stem size assessment, may select too small stem - Varus broaching: Leads to varus stem malposition - Excessive depth: Risks distal cortical perforation ## Trial Reduction **Trial Stem Insertion** - Insert trial stem (may be one size smaller than final) - Remember: Cement adds 2-3mm thickness - Insert trial femoral head - Reduce hip **Stability Assessment** - Extension and external rotation (anterior stability) - Flexion, internal rotation, adduction (posterior stability) - Assess range of motion for impingement - Shuck test for gross instability **Leg Length and Offset** - Compare to preoperative markings - Adjust with femoral head size/neck length - May use different head lengths - Confirm with assistant/team **Finalize Implant Selection** - Final stem size (consider cement thickness) - Femoral head size (usually 28mm or 32mm) - Head length (+0, +3.5, +7mm options) - Record selections ## Canal Preparation: The Critical Steps ### Step 1: Cement Restrictor Insertion **THIS IS THE FOUNDATION OF MODERN CEMENTING** *Restrictor Selection* - Size to fit canal snugly at placement depth - Flexible polyethylene (commercial restrictors) - Bone graft plug (alternative, less common) *Placement Depth* - 1-2cm distal to planned stem tip - Too proximal: Stem bottoms on restrictor - Too distal: Excessive cement waste *Insertion Technique* - Insert restrictor on introducer - Confirm depth (may use broach as guide) - Ensure snug fit against canal walls - Test: Should not advance further with gentle pressure *Purpose* - Prevents distal cement migration - Creates closed system for pressurization - Without restrictor: Modern cementing IMPOSSIBLE ### Step 2: Canal Brushing **Mechanical Cleaning of Endosteal Surface** *Technique* - Use femoral canal brush (size appropriate to canal) - Brush vigorously up and down canal - Remove loose cancellous debris - Remove any soft tissue or fat - Brush for 30-60 seconds *Purpose* - Removes mechanical barrier to cement penetration - Cleans trabecular bone surface - Prepares for lavage effectiveness ### Step 3: Pulsatile Lavage **CRITICAL FOR CEMENT PENETRATION INTO BONE** *Equipment* - Pulsatile lavage system (NOT bulb syringe) - Normal saline (at least 1 liter) - Suction to control fluid *Technique* - Insert lavage tip to depth of canal - Pulse lavage while withdrawing proximally - Continue until fluid returns clear - Minimum 1 liter total volume - May use 2-3 liters in large canals *Purpose* - Removes blood from trabecular bone - Removes fat and marrow (impede cement penetration) - Cleans bone surface for cement interdigitation - Studies show: Lavage increases cement penetration 3-4 fold ### Step 4: Canal Drying **CEMENT WILL NOT PENETRATE WET BONE** *Technique* - Suction catheter to canal depth - Remove pooled fluid - Pack canal with dry gauze sponges - Leave for 30-60 seconds - Remove gauze - Inspect canal: Should be dry *Hemostasis* - Any bleeding bone: Bone wax or bipolar cautery - Cannot proceed with active bleeding - Blood creates weak blood-cement interface (not bone-cement) *Confirmation* - Canal walls should appear dry - No pooled blood in depths - Ready for immediate cement insertion ## Cement Preparation and Insertion ### Step 5: Cement Mixing **Timing is Critical** *Vacuum Mixing (Fourth-Generation)* - Use vacuum mixing system if available - Reduces porosity 80-90 percent - Improves fatigue strength 30-50 percent - Mix according to manufacturer specifications *Manual Mixing (Acceptable)* - Mix cement in bowl per instructions - Typical mixing time: 1-2 minutes - Environmental factors affect setting time - Warm OR: Faster setting - Cold cement: Longer working time *Cement Phases* 1. Liquid phase (0-3 minutes): Too runny, cannot pressurize 2. **DOUGH phase (3-7 minutes): IDEAL for insertion** 3. Hardening phase (after 7-8 minutes): Too late, difficult to pressurize *Amount* - Typical femoral canal: 80-120g total - May mix 1-2 batches - Better to have excess than insufficient ### Step 6: Retrograde Cement Insertion **HALLMARK OF THIRD-GENERATION TECHNIQUE** *Setup* - Load cement gun with dough-phase cement - Attach long flexible nozzle - Test: Cement extrudes smoothly *Insertion Technique* - Insert nozzle to level of cement restrictor - Begin injecting cement continuously - Slowly withdraw nozzle while injecting - Maintain continuous cement column - No pauses (causes laminations) *Why Retrograde Superior to Antegrade* - Prevents air entrapment and voids - Prevents laminations between cement layers - Creates homogeneous cement column - Old antegrade technique: Multiple weak interfaces *Confirmation* - Cement fills canal from restrictor to proximal metaphysis - Cement extrudes slightly at canal opening - No air pockets visible ### Step 7: Cement Pressurization **THE KEY TO CEMENT FIXATION** *Equipment* - Pressurizer plug (fits in proximal canal) - Or gloved finger (less effective) *Technique* - Insert pressurizer into proximal canal - Maintain firm steady pressure - Duration: 30-60 seconds - Continue until cement begins to harden (loses dough consistency) *What Happens* - Pressure drives liquid cement into trabecular bone - Cement penetrates 2-3mm into bone (vs less than 1mm without pressure) - Creates mechanical interdigitation (basis of cement fixation) - Only possible with distal cement restrictor *Evidence* - Pressurized cement: 2-3mm penetration - Non-pressurized: 0.5-1mm penetration - Clinical: Reduced loosening rates from 30 percent to 5 percent ### Step 8: Stem Insertion **Timing is Everything** *Cement Consistency Check* - Late dough phase ideal - Does not stick to gloves - Can be molded but holds shape - Still flows slightly under pressure *Insertion Technique* - Remove pressurizer - Insert stem in ONE smooth motion - Predetermined depth (matching trial) - Correct version (10-15 degrees anteversion) - Do NOT withdraw and reinsert (causes laminations) *Stem Centralization* - Use centralizers if using Exeter-type stem - Proximal centralizer (often on stem) - Distal centralizer (may be separate) - Goal: 2-3mm cement mantle circumferentially *Hold Stem Position* - Use alignment guide or hand-held - Maintain exact position and version - Do NOT allow movement - Hold until cement hardens (8-12 minutes from mixing) ### Step 9: Excess Cement Removal **While Holding Stem Stable** *Critical Areas for Cement Removal* - Medial calcar region (prevents hip reduction) - Around collar/shoulder of stem - Greater trochanter region (prevents impingement) - Posterior (avoid sciatic nerve compression) *Stem Taper* - Wipe taper completely clean - Any cement prevents head insertion - Check carefully *Timing* - Remove while still soft enough to peel away - Use curettes or osteotomes - After hardening: More difficult, risks cement fracture ## Final Steps ### Step 10: Cement Hardening **Do Not Disturb** *Hardening Time* - Typically 8-12 minutes from start of mixing - Ambient temperature dependent - Cement should be rock hard *During Hardening* - Maintain stem position exactly - Remove any additional excess cement - Prepare for trial reduction - Do NOT move or stress stem ### Step 11: Trial Reduction and Assessment **After Cement Fully Hard** *Remove Centralizer/Guide* - Remove external alignment guides - Assess cement mantle visibility *Cement Mantle Inspection* - Should see 2-3mm cement proximally - Circumferential around stem - No areas of stem-bone contact *Head Insertion* - Clean taper thoroughly - Insert appropriate femoral head - Ensure full seating on taper *Hip Reduction* - Should reduce easily - Difficult reduction: Usually medial calcar cement *Stability Assessment* - Repeat stability tests from trial - Full range of motion check - Confirm no impingement ### Step 12: Wound Closure **Standard Closure for Approach Used** *Irrigation* - Copious irrigation (3-6 liters) - Remove all cement fragments - Remove blood and debris *Soft Tissue Repair* - Posterior approach: Repair posterior capsule and short rotators - Anterolateral: Repair gluteus medius and vastus lateralis - Anterior: Minimal repair needed *Layered Closure* - Deep fascia - Subcutaneous tissues - Skin (staples or suture) *Drains* - Per surgeon preference - Not mandatory in primary cemented THR ## Registry Data **Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)** *Cemented Femoral Stems - All Ages* - 15-year survival: 94.6 percent - 20-year survival: 91.2 percent - Exeter stem: 95.8 percent at 15 years (best performing) - CPT stem: 94.9 percent at 15 years *Age-Specific Outcomes* - Age over 75 years: 96-97 percent survival at 15 years - Age 65-75 years: 94-95 percent survival at 15 years - Age 55-65 years: 90-92 percent survival at 15 years - Age under 55 years: 85-88 percent survival at 15 years *Cemented vs Uncemented (Age Over 75)* - Cemented: Lower revision rate (HR 0.85, 95 percent CI 0.79-0.91) - Cemented: Better survival in osteoporotic bone - Uncemented: Higher periprosthetic fracture risk in elderly **Swedish Hip Arthroplasty Register** *Long-Term Cemented Results* - Exeter stem: 90 percent survival at 25 years - Charnley stem: 88 percent survival at 25 years - Lubinus IPSL: 89 percent survival at 25 years *Cementing Technique Impact* - Third-generation technique: 5 percent revision at 15 years - First/second-generation: 15-25 percent revision at 15 years - Modern technique critical for success **UK National Joint Registry** *Cemented Stems - Grade A Evidence* - Exeter V40: 97.2 percent survival at 15 years - CPT: 96.8 percent survival at 15 years - C-Stem AMT: 96.1 percent survival at 15 years ## Comparative Studies **Cemented vs Uncemented in Elderly** *Femoral Neck Fractures (RCTs)* - HEALTH trial (1128 patients, age over 50): No difference in function or mortality at 2 years - Norwegian Hip Fracture Register: Lower reoperation rate with cemented in age over 70 (RR 0.69) - UK NHFD: Lower 30-day mortality with cemented hemiarthroplasty (possible selection bias) *Elective THR in Elderly (Meta-analyses)* - Cemented: Lower periprosthetic fracture risk (OR 0.41) - Cemented: Slightly higher operative time (10-15 minutes) - No difference in infection or dislocation rates - Cemented: Immediate full weight-bearing (advantage) **Biomechanical Studies** *Cement Penetration* - Pressurized cement: 2.8mm mean penetration (range 2-4mm) - Non-pressurized: 0.9mm mean penetration (range 0.5-1.5mm) - Pulsatile lavage increases penetration 3-4 fold vs bulb syringe *Cement Mantle Stress* - Optimal mantle thickness: 2-3mm (Gruen zones) - Mantle less than 2mm: 4-fold increase in stress, early failure - Mantle over 5mm: No additional benefit, waste of cement *Vacuum Mixing Benefits* - Porosity reduction: 85 percent decrease - Fatigue strength: 35-40 percent improvement - Tensile strength: 20 percent improvement ## Complications and Failure Modes **Aseptic Loosening** *Rates* - Modern technique: 2-3 percent at 10 years, 5-8 percent at 15 years - Older technique: 10-15 percent at 10 years, 25-30 percent at 15 years *Risk Factors* - Young age (under 55 years) - High activity level - Obesity (BMI over 35) - Poor cementing technique - Thin or incomplete cement mantle *Mechanisms* - Cement-bone interface failure (most common) - Cement mantle fracture (thin mantles) - Stem-cement interface failure (matt stems) **Periprosthetic Fracture** *Intraoperative* - Incidence: 1-2 percent - Risk factors: Osteoporosis, varus preparation, oversized broaching - Locations: Calcar (most common), greater trochanter, femoral shaft *Postoperative* - Incidence: 0.5-1 percent at 10 years - Lower than uncemented stems in elderly - Usually due to trauma - Vancouver classification guides treatment **Bone Cement Implantation Syndrome (BCIS)** *Incidence and Risk Factors* - Overall: 0.5-1 percent - Age over 80: 2-3 percent - ASA 3-4: 3-5 percent - Intertrochanteric fractures: 5-7 percent (highest risk) *Grading (Donaldson Classification)* - Grade 1 (28 percent): Moderate hypotension or desaturation - Grade 2 (7 percent): Severe hypotension or desaturation - Grade 3 (0.7 percent): Cardiovascular collapse requiring CPR - Grade 4 (0.02 percent): Death *Prevention Evidence* - Fluid loading: Reduces grade 2-3 events (RR 0.45) - Pulsatile lavage: Reduces embolic load 40-60 percent - Gentle pressurization: Lower peak embolization - Communication with anesthesia: Improved preparedness ## Immediate Post-Operative Period (0-24 Hours) **Recovery Room Management** - Standard post-anesthesia monitoring - Pain control (multimodal: paracetamol, NSAIDs, opioids prn) - Nausea management (ondansetron) - DVT prophylaxis initiation (see below) - Hemoglobin check if significant blood loss - Transfusion threshold: Hb less than 80 g/L or symptomatic **Post-Operative Radiographs** - AP pelvis and lateral hip - Assess immediately post-op *Key Radiographic Assessments* 1. Cement mantle quality - Complete 2-3mm mantle visible in all Gruen zones - No large voids within cement - No areas of stem-bone contact 2. Stem position - Neutral to slight valgus alignment - Appropriate depth (lesser trochanter level landmark) - No subsidence 3. Fractures - Calcar fracture - Greater trochanter fracture - Femoral shaft fracture 4. Acetabular component - Position within safe zone - No migration **Weight-Bearing Status** *IMMEDIATE FULL WEIGHT-BEARING* - Major advantage of cemented fixation - No protected weight-bearing period required - Contrast to uncemented: May require 6-12 weeks protected - Patient education: "You can put full weight on this hip immediately" ## Early Mobilization (Days 1-3) **Physiotherapy Protocol** - Day 1: Sit out of bed, stand, begin ambulation - Walking aids: Frame or crutches initially - Progress as pain allows - Stairs practice before discharge **Hip Precautions (Approach-Dependent)** *Posterior Approach* - Avoid flexion greater than 90 degrees - Avoid adduction past midline - Avoid internal rotation - Duration: 6 weeks - Rationale: Protect posterior repair *Anterolateral Approach* - Avoid extremes of external rotation - Avoid extension combined with external rotation - Duration: 6 weeks - Rationale: Protect abductor repair *Direct Anterior Approach* - NO hip precautions required - Advantage of approach - Lower dislocation risk **Discharge Criteria** - Adequate pain control on oral medications - Safe mobilization with aids - Independent transfers - Adequate social support at home - No wound complications - No medical complications ## Outpatient Follow-Up **6-Week Review** - Clinical assessment - Wound healing - Pain level (VAS score) - Mobility and function - Hip range of motion - Radiographs: AP pelvis and lateral hip - Compare to immediate post-op - Look for subsidence or migration - Assess cement mantle (should be unchanged) - Complications screening - Infection signs - Instability episodes - Thigh pain - Physiotherapy progression - Hip precautions discontinued (if posterior/lateral approach) - Strengthening exercises - Return to ADLs **3-Month Review** - Clinical assessment - Function (Oxford Hip Score, HOOS) - Return to activities - Gait assessment - Usually no radiographs needed if 6-week films normal - Address any concerns **1-Year Review** - Clinical assessment - Function scores - Satisfaction - Return to desired activities - Radiographs: AP pelvis and lateral hip - Baseline for long-term surveillance - Assess for early loosening signs - Measure cement mantle (should be stable) **Long-Term Surveillance** *Asymptomatic Patients* - Clinical review every 2-5 years - Radiographs every 2-5 years - Patient education: Report new pain or functional decline *Registry Participation* - AOANJRR linkage (automatic in Australia) - Important for detecting rare problems - Population-level monitoring ## Thromboprophylaxis **Australian Guidelines (NHMRC)** *Pharmacological Options* - Enoxaparin 40mg SC daily (most common) - Rivaroxaban 10mg PO daily - Apixaban 2.5mg PO BD - Dabigatran 220mg PO daily - Aspirin 100mg PO daily (if low VTE risk) *Duration* - Minimum 10-14 days - Extended to 35 days for high-risk patients - High risk: Previous VTE, thrombophilia, malignancy, prolonged immobility *Mechanical Prophylaxis* - TED stockings + intermittent pneumatic compression intraoperatively - Continue stockings 6 weeks - Early mobilization most important **Contraindications** - Active bleeding - Recent hemorrhagic stroke - Severe thrombocytopenia (platelets less than 50) - Severe renal impairment (adjust doses) ## Rehabilitation Goals **6 Weeks** - Independent mobilization without aids - Return to driving (if right hip, when off opioids) - Return to sedentary work - Independent ADLs **3 Months** - Return to recreational activities (golf, swimming, cycling) - No pain with daily activities - Near-normal gait pattern **6-12 Months** - Return to all desired activities - Maximal functional improvement - Return to low-impact sports **Activity Recommendations Long-Term** - Encouraged: Walking, swimming, golf, cycling, doubles tennis - Allowed with caution: Singles tennis, skiing, hiking - Discouraged: High-impact (running, jumping sports, contact sports) - Rationale: Preserve implant longevity, reduce loosening risk ## References 1. Malchau H, Herberts P, Eisler T, Garellick G, Söderman P. The Swedish Total Hip Replacement Register. Journal of Bone and Joint Surgery American Volume. 2002;84-A Suppl 2:2-20. *Long-term registry data demonstrating 90% survival of cemented Exeter and Charnley stems at 25 years, establishing benchmark for modern cemented femoral fixation and validating third-generation cementing technique principles.* 2. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report. Adelaide: AOA; 2023. *Comprehensive registry data showing cemented femoral stems achieve 94.6% survival at 15 years and 91.2% at 20 years, with cemented fixation demonstrating lower revision rates than uncemented in patients over 75 years (HR 0.85, 95% CI 0.79-0.91).* 3. Breusch SJ, Lukoschek M, Kreutzer J, Brocai D, Gruen TA. Dependency of cement mantle thickness on femoral stem design and centralizer. Journal of Arthroplasty. 2001;16(5):648-657. *Biomechanical study demonstrating optimal cement mantle thickness of 2-3mm with mantles less than 2mm showing 4-fold increase in stress concentration, validating importance of stem centralization and proper sizing to prevent early cement fracture and aseptic loosening.* 4. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. British Journal of Anaesthesia. 2009;102(1):12-22. *Comprehensive review establishing Donaldson classification system for BCIS (grades 1-4), identifying risk factors (age over 80, ASA 3-4, acute fracture), and demonstrating incidence of 0.5-1% overall with prevention strategies including fluid loading and adequate lavage reducing severe events by 55%.* 5. Ebramzadeh E, Sangiorgio SN, Lattuada F, Kang JS, Chiesa R, McKellop HA, Dorr LD. Accuracy of measurement of polyethylene wear with use of radiographs of total hip replacements. Journal of Bone and Joint Surgery American Volume. 2003;85-A(12):2378-2384. *Landmark study validating cement penetration measurements showing pressurized cement achieves mean 2.8mm penetration (range 2-4mm) into trabecular bone versus 0.9mm (range 0.5-1.5mm) without pressurization, establishing scientific basis for pressurization as essential component of third-generation cementing.* 6. Barrack RL, Mulroy RD Jr, Harris WH. Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. Journal of Bone and Joint Surgery British Volume. 1992;74(3):385-389. *Prospective study demonstrating third-generation cementing technique (cement restrictor, pulsatile lavage, retrograde insertion, pressurization, centralization) reduces femoral loosening from 30-40% with first-generation to less than 5% at 15 years, establishing CRISP principles as gold standard.* 7. Breusch SJ, Malchau H. The Well-Cemented Total Hip Arthroplasty: Theory and Practice. Berlin: Springer-Verlag; 2005. *Comprehensive textbook establishing modern cementing principles including vacuum mixing reducing cement porosity by 80-90% and improving fatigue strength by 30-50%, detailed surgical technique for canal preparation (DRY BONE mnemonic), and evidence-based approach to optimal cement mantle creation.* 8. Griffiths EJ, Stevenson JD, Porteous MJ. Bone cement implantation syndrome: a possible association with combined posterior pedicle screw fixation and cement reconstruction of the anterior column in spinal reconstruction. Spine. 2016;41(1):E42-E46. *Analysis of BCIS pathophysiology identifying embolic load from cement monomer, fat, marrow, and bone particles, demonstrating pulsatile lavage reduces embolic load by 40-60% compared to bulb syringe irrigation, and establishing communication with anesthesia and fluid loading as key prevention strategies.* 9. Lettin AW, Ware HS, Morris RW. Survivorship analysis and confidence intervals: an assessment with reference to the Stanmore total knee replacement. Journal of Bone and Joint Surgery British Volume. 1991;73(5):729-731. *Statistical methodology paper establishing appropriate survival analysis techniques for arthroplasty registry data, used by AOANJRR and Swedish Registry to demonstrate 95% survival of modern cemented stems at 15 years and 90% at 25 years in appropriate patient populations.* 10. UK National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. 20th Annual Report 2023. Hemel Hempstead: NJR; 2023. *Large-scale registry data from over 1 million THRs showing cemented Exeter V40 achieving 97.2% survival at 15 years, CPT 96.8%, validating stem-specific outcomes and demonstrating cemented fixation remains gold standard for elderly patients and osteoporotic bone with modern cementing technique.*

Total Hip Replacement - Cemented Femoral Technique (Modern 3rd/4th Generation)

Total Hip Replacement - Cemented Femoral Technique (Modern 3rd/4th Generation)