Revision total hip surgery requires a number of techniques that optimizes outcomes while minimizing bone loss. One such technique that has proven useful in revision of the femoral components in revision total hip surgery is leaving an intact cement mantle in place and cementing a new prosthesis within the intact cement mantle. Careful patient selection and preoperative planning are essential for the successful implementation of this technique. The appropriate indications are: (1) if the original stem is broken, but the cement mantle is intact, (2) when removing a well-fixed, cemented stem to improve exposure for an acetabular revision, increase femoral offset, or femoral head diameter, and (3) when removing a debonded femoral component. Although the cement-within-cement revision technique is rarely used, it is an important technique to have in your portfolio. However, it is also important to keep in mind some of the drawbacks of cement-within-revisions and to consider these factors when deciding whether this technique is appropriate for a specific patient.
Recent literature has supported the use of cement within cement for femoral revisions, provided the patient selection is appropriate and good surgical technique is used. Lieberman et al1 studied 19 cement-within-cement femoral revisions, with mean follow-up 59 months after surgery and reported 95% good-to-excellent results. Of these 19 patients, only 3 experienced complications: 2 patients had femoral perforations and 1 patient had a dislocation. Recent outcomes have improved compared to those seen in the late 1970s and 1980s, partly because of the advancement in cementing techniques. In general, there are 4 main techniques for femoral component revisions: (1) noncemented, modular, metaphyseal loading (eg, S-ROM); (2) noncemented, modular, diaphyseal loading using a fully porous-coated, cylindrical stem or proximally coated, tapered stem; (3) cemented long stem components (rare); and (4) cement within cement. The majority of revisions are still noncemented; however, one must know how to perform cement-within-cement femoral revisions, fully understanding the technique and appropriate patient selection to enhance the chances of success.
The most important prerequisite for using a cement-within-cement technique is an intact cement mantle. If the cement mantle is not intact, another revision technique should be used. Three common situations can indicate the use of a cement-within-cement technique: (1) if the original stem is broken, but the cement mantle is intact; (2) when removing a well-fixed, cemented stem to improve exposure for an acetabular revision, increase femoral offset or femoral head diameter, or place a new bearing femoral head (especially in the case of nonmodular femoral components); and (3) when removing a debonded femoral component.
Before beginning a cement-within-cement femoral arthroplasty revision, it is important to first inspect the cement-bone interface intraoperatively. The distal two-thirds of the cement-bone interface must be intact. If so, then any loose proximal cement should first be curetted out. Then, the superficial layer of the cement should be roughened with a high-speed burr or ultrasound ablator, which increases the surface area of the old cement, allowing the new cement to integrate more effectively, as well as allowing more room in the canal for the new cement. If malposition is a concern, selective removal of old cement should be performed to allow the new stem to be positioned correctly. This can be done using an osteotome, curette, and a high-speed burr or ultrasound ablator. Then, the correct stem must be chosen for the revision. Because the femoral shaft already contains a layer of old cement, the new stem should be smaller than the old stem, but of a similar design. This will prevent the new stem from being too long or too wide (in the anteroposterior dimensions), as was a common problem with older monoblock stems. When using the high-speed burr or ultrasound ablator, exercise extra caution to prevent femoral perforation. Once the femoral canal has been cleaned out and prepared, it is critical to dry the canal as fully as possible. Once the canal is dry, the new cement can be injected into the canal. The cement should be injected in the liquid phase to prevent lamination and to promote integration between the old and new cement.2
Although the cement-within-cement revision technique is rarely used, it is an important technique to have in your portfolio. However, it is also important to keep in mind some of the drawbacks of cement-within-cement revisions and to consider these factors when deciding whether this technique is appropriate for a specific patient. Studies have shown that a revised cement-bone interface is 30% weaker in shear strength than a primary cement-bone interface.3 Similarly, the old cement–new cement interface is as much as 85% weaker in shear strength than a uniform block of cement due to the unavoidable presence of contaminants such as blood and marrow debris.4 Although the cement-within-cement technique will result in a significantly weaker revision than if the old cement mantle was entirely removed and replaced, reduced complications and a shorter surgery time make a cement-within-cement revision a good option for some patients.5 In fact, recent studies of cement-within-cement revisions have reported good outcomes. Marcos et al6 observed 37 cement-within-cement revisions performed between 1999 and 2005, and found that no patients required further femoral revision at an average follow-up of 46 months postoperativley. Thus, it is important to be knowledgeable about cement-within-cement revisions and be able to use this technique in the appropriate patient population.
- Lieberman JR, Moeckel BH, Evans BG, Salvati EA, Ranawat CS. Cement-within-cement revision hip arthroplasty. J Bone Joint Surg Br. 1993; 75(6):869-871.
- Lieberman JR. Cemented femoral revision: lest we forget. J Arthroplasty. 2005; 20(4 Suppl 2):72-74.
- Rosenstein A, MacDonald W, Iliadis A, McLardy-Smith P. Revision of cemented fixation and cement-bone interface strength. Proc Inst Mech Eng H. 1992; 206(1):47-49.
- Li PL, Ingle PJ, Dowell JK. Cement-within-cement revision hip arthroplasty: should it be done? A biomechanical study. J Bone Joint Surg Br. 1996; 78(5):809-811.
- Quinlan F, O’Shea K, Doyle F, Brady OH. In-cement technique for revision hip arthroplasty. J Bone Joint Surg Br. 2006; 88(6):730-733.
- Marcos L, Buttaro M, Comba F, Piccaluga F. Femoral cement within cement technique in carefully selected aseptic revision arthroplasties. Int Orthop. 2009; 33(3):633-637.
Drs Cross and Bostrom are from the Hospital for Special Surgery, New York, New York.
Drs Cross and Bostrom have no relevant financial relationships to disclose.
Presented at Current Concepts in Joint Replacement 2008 Winter Meeting; December 10-13, 2008; Orlando, Florida.
Correspondence should be addressed to: Mathias Bostrom, MD, 535 E 70th St, New York, NY 10021.