Secondary cement injection technique reduces pulmonary embolism in total hip arthroplasty

Abstract

Purpose Cardio-pulmonary damage due to embolism is a feared complication of cemented hip arthroplasty and can be fatal. Embolic events result from an increased intramedullary pressure during cement and stem insertion and can lead to extrusion of bone-marrow elements into the circulation. To reduce embolism and at the same time achieve an ideal cement mantle, the cement injection stem has been designed. In contrast to conventional stems where cement applied before stem insertion (primary cementing technique), the cement injection stem is positioned first and only then is the cement injected via the stem in a volume-and pressure-controlled fashion (secondary cementing technique). Methods A randomised trial with 30 patients was performed to evaluate whether this technique is able to reduce embolic events. Patients either received a conventional cemented stem (primary cementing technique) or a cement injection stem (secondary cementing technique). Embolic events were recorded by transesophageal echocardiography at six specific points during the operation and classified from grade 0 to grade 3.Results Significantly fewer grade 2 and 3 embolic events were observed in patients receiving the cement injection stem using the secondary cementing technique. Moreover, in the conventional group all patients (100 %) had at least one grade 3 embolus whereas only 20 % with the secondary cementing technique had an embolic event of grade 3. Conclusion Secondary cement insertion via the cement injection stem is able to reduce severe embolic events significantly. The technique offers a more gentle cementing technique and therefore appears especially beneficial for patients of advanced age and/or with pre-existing cardiopulmonary comorbidities.

Fat Embolism Syndrome and in-Hospital Mortality Rates According to Patient Age: A Large Nationwide Retrospective Study

“…No significant difference was noted among patients that required bone grafting (p=0.63), internal fixation without fracture reduction (p=0. 43), and open reduction without internal fixation (p=0.087).…”

“… 42 These patients may have less likely to receive treatment than other patients. Schmidutz et al 43 conducted a randomized trial with 30 patients and observed that secondary cement insertion was able to reduce severe embolic events. With regards to reaming technique, intramedullary reaming has the theoretical higher odds of increasing FES due to the increase in canal pressure and stimulation of an inflammatory response, yet studies have been limited by small sample sizes and this topic requires further investigation.…”

The Bone Cement Hypercoagulation Syndrome: Pathophysiology, Mortality, and Prevention

“…Additionally, prophylactic measures such as high-pressure irrigation of the broached femoral channel, distal plugs, venting catheters, distal cortical drill holes, lavage, bone-vacuum suctioning, and secondary cementation have been studied and found to reduce surgical trauma. [113][114][115][116][117][118] Despite these prophylactic measures, installation of hip prostheses without methacrylate cement remains the approach of choice in comorbid patients. [110][111][112] Other prophylactic measures, such as pre-treatment with heparin or a thrombin inhibitor, neutralize most of the coagulation activity and reduce mortality.…”

Water Jet Applicator for Interface Tissue Removal in Minimally Invasive Hip Refixation: Testing the Principle and Design of Prototype

“…A pressure of approximately 2000 mmHg (267 kPa) is assumed to be sufficient to obtain an adequate cement mantle [22,23]. Cement applicators that stop automatically at a pressure of 267 kPa were successfully tested (clinically) [24,25]. Based on the earlier studies [22][23][24][25], the increase in intramedullary pressure should stay below 267 kPa while applying the waterjet, which is comparable to the injection pressure during hip stem cementing.…”