thr cemented vs uncementd
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Primary Total Hip ReplacementCemented vs Un cemented
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Total Hip ReplacementTypes ( based on fixation technique )
• Cemented• Un cemented• Hybrid• Reverse hybrid
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Implant selection
• Patients age• Underlying bone pathology• Type of medullary canal
DORR classification
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Cemented stems
• Elderly patients , particularly females• Inflammatory and metabolic bone disease• Cylindrical morphology of proximal femur ( DORR C )
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Cement less stems
• Younger and relatively younger patients• AVN, osteoarthritis, Post traumatic arthritis• Funnel shaped proximal femur ( DORR A )
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Cemented stem designs
• Taper slip• Composite beam
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Taper slip design
• Collar less, tapered• Subsidence results in tighter wedging• Shear converted into compressive stresses
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Composite beam design
• Collared• Rough surface• Co-Chrome (stiff ) stem• Strain on cement mantle reduced
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Cementing technique
• Broach only technique• Antibiotic cement• Third generation cementing• Uniform cement mantle 2 to 3 mm thick
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Cement less ( Press fit ) designs
• Tapered• Cylindrical• Anatomic
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Tapered stem design
First generation• Load femur proximally only• Proximally coated• Tapered AP and ML• No collarSecond generation• Rotational ridges and polished tip
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Cylindrical stem design
First generation• Cylindrical distally and distal press fit• Extensively porous coated• Usually collaredSecond generation• Better proximal fit• Distal flutes and coronal slots• Polished tip
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Anatomic stem design
First generation• Better proximal fill and fit• Anteverted necks ( right and left )• Significant thigh pain and osteolysis
Second generation• Bowed tip eliminated• Flattened posterior and lateral sides
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Types of porous coatingSecondary stability
• Sintering• Diffusion bonding• Plasma spraying
Optimal pore size 100 to 400 µm
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Interphase dynamics
• Gap should be < 0.5 mm• Micro motion should be < 50 µm
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Ceramic coating
• Hydroxyapatite • Tri calcium phosphate
• Fills Bone Implant gaps• Bioactive and bio-absorbable
• Particulate disease• Heterotopic bone
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Cemented acetabular component
All poly cup
• Hypotensive anaesthesia• Good cancellous bed• Proper cement pressurization
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Cement less acetabular component
• Hemispheric cups with porous coating• Fixation with press fit or screws
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Cement less acetabular component
• Screw holes eliminated or reduced• Polished inner surface• Improved socket liner conformity and locking
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Out comes
• Medium and long time Survival rates are good for both types of femoral components
• Pelvic osteolysis is still a problem with both types of cups
• Loosening is a problem with cemented acetabular components after the first decade
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Technique and time
Cemented THR is technically more demanding
• Blood less field• Cement pressurization• Uniform and homogenous cement mantle
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Post op. weight bearing
Cemented immediate
Un cemented 4 to 6 weeks immediate if fill and fit is good
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Peri-prosthetic fractures
• More common with un cemented• More on the femoral side and in elderly
females
• Intra op. fractures 0.3 % ( cemented ) 5.4 % ( un cemented ) ( Mayo clinic registry )
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Deep infections
No difference between the types-
when Cemented THR is done with antibiotic impregnated cement
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Dislocations
More common with un cemented due to imperfect version and soft tissue balancing
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Cost
• Manufacturing cost of un cemented implants is more
• With cemented THR - cement , related equipment, increased operating room time
• Cost difference is $ 300
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Recent Trends
Swedish Hip Registry 2008 Australian Jt Registry 2009
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Summary Cemented or un cemented
Elderly patients , particularly females with poor bone quality ----- cemented hip.
Otherwise ------ un cemented hip
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SummaryUn cemented hips
Implants
Femur Tapered, proximally coated Acetabulum Hemispheric cup without holes
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SummaryUn cemented hips
• Appropriate implant size• Careful insertion• Primary implant stability with press fit For adequate osseous integration• Literature does not support routine usage of
ceramic coated implants
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SummaryCemented hips
Implants
Femur tapered, collar less, smooth surface Acetabulum Highly cross linked all poly
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SummaryCemented hips
• Blood less cancellous acetabular bed• Cement pressurization
• Third generation cementing technique• Uniform, homogenous cement mantle
• Be ware of embolic manifestations in cardio-pulmonary compromised patients
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Thank you