Document Type: RESEARCH PAPER

Authors

1 BRJ Orthocentre and MAK Hospital, Eru Company Stop, Mettupalayam Road, Coimbatore, India

2 Amrita Institute of Medical Sciences, Ponekkara, Edappally, Kochi, Kerala, India

3 Kovai Medical Centre Hospital, Avanashi road, Peelamedu, Coimbatore, Tamil Nadu, India

4 Maxcure Hospitals, Hitech City, Madhapur, Hyderabad, Telangana, India

5 Sagar Hospital Banashankari, DSI Institutions kumarasamy layout, Bangalore, India

Abstract

Background: No scientific evidence exists regarding the amount of bone cement used and discarded in primary
cemented Total knee arthroplasty (TKA). The aim of this study was to identify the exact amount of bone cement utilized
for component fixation in primary TKA.
Methods: In a prospective study carried out at five centers, 133 primary cemented TKAs were performed. One pack
of 40g Palacos bone cement (PBC 40) was hand mixed and digitally applied during the surgery. After fixation of the
TKA components, the remaining bone cement was methodically collected and weighed on a digital weighing scale. The
actual quantity of cement utilized for component fixation was calculated.
Results: On an average, 22.1 g of bone cement was utilized per joint, which accounted to 39 % of 57 g, the solidified
dry weight of PBC 40. Among 133 knees, the cement usage was 20 % to 50% in 109 knees, more than 50% in 20 knees
and less than 20% in 4 knees. Knees which received larger sized femoral implant required more cement compared to
medium and small sizes. Knees which had pulse lavage had more cement utilization compared to knees which had
simple syringe lavage before implantation.
Conclusion: Large quantity of bone cement was handled than actual requirements in primary TKA when a
standard 40g pack was used with the digital application technique, resulting in sizeable discard of bone cement.
Customizing cement pack according to the implant size can potentially avoid this cement wastage. Future
research is required to study the utility and economic impact of smaller packs (20 g or 30 g) of bone cement in
primary TKA.
Level of evidence: IV

Keywords

Main Subjects

1. Aprato A, Risitano S, Sabatini L, Giachino M, Agati
G, Massè A. Cementless total knee arthroplasty. Ann
Transl Med. 2016; 4(7):129.
2. Dalury DF. Cementless total knee arthroplasty: current
concepts review. Bone Joint J. 2016; 98-B(7):867-73.
3. Ritter MA, Keating EM, Sueyoshi T, Davis KE,
Barrington JW, Emerson RH. Twenty-five-years and
greater, results after nonmodular cemented total knee
arthroplasty. J Arthroplasty. 2016; 31(10):2199-202.
4. Patil S, McCauley JC, Pulido P, Colwell CW Jr. How
do knee implants perform past the second decade?
Nineteen- to 25-year followup of the Press-fit
Condylar design TKA. Clin Orthop Relat Res. 2015;
473(1):135-40.
5. Rodriguez-Merchan EC. Does a previous high tibial
osteotomy (HTO) influence the long-term function
or survival of a total knee arthroplasty (TKA)? Arch
Bone Jt Surg. 2018, 6(1):19-22.
6. Vaishya R, Chauhan M, Vaish A. Bone cement. J Clin
Orthop Trauma. 2013; 4(4):157-63.
7. Nedungayil SK, Mehendele S, Gheduzzi S, Learmonth
ID. Femoral cementing techniques: current trends in
the UK. Ann R Coll Surg Engl. 2006; 88(2):127-30.
8. Silverman EJ, Landy DC, Massel DH, Kaimrajh DN,
Latta LL, Robinson RP. The effect of viscosity on
cement penetration in total knee arthroplasty, an
application of the squeeze film effect. J Arthroplasty.
2014; 29(10):2039-42.
9. Vanlommel J, Luyckx JP, Labey L, Innocenti B, De Corte
R, Bellemans J. Cementing the tibial component in
total knee arthroplasty: which technique is the best? J
Arthroplasty. 2011; 26(3):492-6.
10. Vaninbroukx M, Labey L, Innocenti B, Bellemans
J. Cementing the femoral component in total knee
arthroplasty: which technique is the best? Knee.
2009; 16(4):265-8.
11. Miller MA, Goodheart JR, Izant TH, Rimnac CM, Cleary
RJ, Mann KA. Loss of cement-bone interlock in retrieved
tibial components from total knee arthroplasties. Clin
Orthop Relat Res. 2014; 472(1):304-13.
12. Verburg H, van de Ridder LC, Verhoeven VW, Pilot P.
Validation of a measuring technique with computed
tomography for cement penetration into trabecular
bone underneath the tibial tray in total knee
arthroplasty on a cadaver model. BMC Med Imaging.
2014; 14(1):29.
13. Hinarejos P, Guirro P, Puig-Verdie L, Torres-Claramunt
R, Leal-Blanquet J, Sanchez-Soler J, et al. Use of
antibiotic-loaded cement in total knee arthroplasty.
World J Orthop. 2015; 6(11):877-85.
14. Van de Groes SA, de Waal Malefijt MC, Verdonschot N.
Influence of preparation techniques to the strength of
the bone-cement interface behind the flange in total
knee arthroplasty. Knee. 2013; 20(3):186-90.
15. Shi D, Xu X, Guo A, Dai J, Xu Z, Chen D, et al. Bone
cement solidification influence the limb alignment

and gap balance during TKA. Biomed Res Int. 2015;
2015(1):109402.
16. Bindelglass DF, Cohen JL, Dorr LD. Patellar tilt and
subluxation in total knee arthroplasty. Relationship to
pain, fixation, and design. Clin Orthop Relat Res. 1993;
286(1):103-9.
17. Maheshwari AV, Argawal M, Naziri Q, Pivec R, Mont
MA, Rasquinha VJ. Can cementing technique reduce
the cost of a primary total knee arthroplasty? J Knee
Surg. 2015; 28(3):183-90.
18. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total
knee arthroplasty volume, utilization, and outcomes
among Medicare beneficiaries, 1991-2010. JAMA.
2012; 308(12):1227-36.
19. Hauptmann SM, Weber P, Glaser C, Birkenmaier C,
Jansson V, Müller PE. Free bone cement fragments
after minimally invasive unicompartmental knee
arthroplasty: an underappreciated problem. Knee
Surg Sports Traumatol Arthrosc. 2008; 16(8):770-5.
20. Elmadağ M, Imren Y, Erdil M, Bilsel K, Tuncay I. Excess
retained cement in the posteromedial compartment
after unicondylar knee arthroplasty. Acta Orthop
Traumatol Turc. 2013; 47(4):291-4.
21. Jung KA, Lee SC, Song MB. Lateral meniscus and
lateral femoral condyle cartilage injury by retained
cement after medial unicondylar knee arthroplasty. J
Arthroplasty. 2008; 23(7):1086-9.
22. Kim WY, Shafi M, Kim YY, Kim JY, Cho YK, Han CW.
Posteromedial compartment cement extrusion
after unicompartmental knee arthroplasty treated
by arthroscopy: a case report. Knee Surg Sports
Traumatol Arthrosc. 2006; 14(1):46-9.
23. Otani T, Fujii K, Ozawa M, Kaechi K, Funaki K, Matsuba
T, et al. Impingement after total knee arthroplasty
caused by cement extrusion and proximal tibiofibular
instability. J Arthroplasty. 1998; 13(5):589-91.
24. Schlegel UJ, Püschel K, Morlock MM, Nagel K. An in
vitro comparison of tibial tray cementation using gun
pressurization or pulsed lavage. Int Orthop. 2014;
38(5):967-71.
25. Messick KJ, Miller MA, Damron LA, Race A, Clarke MT,
Mann KA. Vacuum-mixing cement does not decrease
overall porosity in cemented femoral stems: an in
vitro laboratory investigation. J Bone Joint Surg Br.
2007; 89(8):1115-21.
26. Hoey D, Taylor D. Quantitative analysis of the effect of
porosity on the fatigue strength of bone cement. Acta
Biomater. 2009; 5(2):719-26.
27. Ling RS, Lee AJ. Porosity reduction in acrylic cement
is clinically irrelevant. Clin Orthop Relat Res. 1998;
355(1):249-53.
28. Janssen D, Aquarius R, Stolk J, Verdonschot N. The
contradictory effects of pores on fatigue cracking of
bone cement. J Biomed Mater Res B Appl Biomater.
2005; 74(2):747-53.
29. Macaulay W, DiGiovanni CW, Restrepo A, Saleh KJ,
Walsh H, Crossett LS, et al. Differences in bone-cement
porosity by vacuum mixing, centrifugation, and hand
mixing. J Arthroplasty. 2002; 17(5):569-75.
30. Kopec M, Milbrandt JC, Duellman T, Mangan D,
Allan DG. Effect of hand packing versus cement
gun pressurization on cement mantle in total knee
arthroplasty. Can J Surg. 2009; 52(6):490-4.
31. Schlegel UJ, Bishop NE, Püschel K, Morlock MM,
Nagel K. Comparison of different cement application
techniques for tibial component fixation in TKA. Int
Orthop. 2015; 39(1):47-54.