Ultrasonic bone cement removal efficiency in total joint arthroplasty revision: A computer tomographic‐based cadaver study

Abstract

Polymethylmethacrylate (PMMA) removal during septic total joint arthroplasty revision is associated with a high fracture and perforation risk. Ultrasonic cement removal is considered a bone‐preserving technique. Currently, there is still a lack of sound data on efficacy as it is difficult to detect smaller residues with reasonable technical effort. However, incomplete removal is associated with the risk of biofilm coverage of the residue. Therefore, the study aimed to investigate the efficiency of ultrasonic‐based PMMA removal in a human cadaver model. The femoral components of a total hip and a total knee prosthesis were implanted in two cadaver femoral canals by 3rd generation cement fixation technique. Implants were then removed. Cement mantle extraction was performed with the OSCAR‐3‐System ultrasonic system (Orthofix®). Quantitative analysis of cement residues was carried out with dual‐energy and microcomputer tomography. With a 20 µm resolution, in vitro microcomputer tomography visualized tiniest PMMA residues. For clinical use, dual‐energy computer tomography tissue decomposition with 0.75 mm resolution is suitable. With ultrasound, more than 99% of PMMA was removed. Seven hundred thirty‐four residues with a mean volume of 0.40 ± 4.95 mm3 were identified with only 4 exceeding 1 cm in length in at least one axis. Ultrasonic cement removal of PMMA was almost complete and can therefore be considered a highly effective technique. For the first time, PMMA residues in the sub‐millimetre range were detected by computer tomography. Clinical implications of the small remaining PMMA fraction on the eradication rate of periprosthetic joint infection warrants further investigations.

Application of Piezosurgery in Revision Surgery through Posterior Approach for Infection after Percutaneous Vertebral Augmentation: Technique Note with Case Series

“… 20 In addition to the reduced bleeding and less damage to bony structures in the resection of articular processes, lamina, and other corresponding structures, piezosurgery can better clear the infected bone cement tissue. According to Roitzsch et al, 21 piezosurgery is a highly effective technique and removes more than 99% of the PMMA. It has been confirmed in bone revision surgery of extremities and has achieved satisfactory clinical results.…”

Periprothetische Infektionen – operatives und medikamentöses Management

“…Antiseptische Lösungen mit dem physiologisch lysosomal vorkommenden Oxidationsmittel Natriumhypochlorit, welches zu einer Schädigung der bakteriellen Zellmembran führt, weisen eine gute Gewebeverträglichkeit ohne Allergiepotenzial auf. Neben der mechanischen Zemententfernung unter Verwendung spezieller Instrumente (Meißel, Rückziehhaken, Gewindeschneider, flexible Markraumbohrer) können knochenschonende Verfahren zur ultraschallgestützten Zemententfernung genutzt werden [22].…”

Tipps und Tricks für die Zemententfernung im Revisionsfall

“…Im Falle einer periprothetischen Infektion wird die radikale und vollständige Zemententfernung von den Autoren empfohlen. Bei aseptischen Prothesenlockerungen werden in der aktuellen Literatur zwei Strategien diskutiert [ 6 , 10 , 11 ]. Eine Möglichkeit besteht im Wechsel einer zementierten Prothese auf eine zementfreie Variante [ 12 , 13 ].…”

“…Vor allem bei septischen Wechseleingriffen sind verbliebende Zementreste relevant ursächlich für neuerlich notwendige Revisionsoperationen. Darüber hinaus können verbliebende Zementreste auch mechanische Komplikationen bedingen [ 6 , 7 ]. Daher kommt der gewissenhaften und vollständigen Zemententfernung im Revisionsfall eine große Bedeutung zu.…”