A potential need for surgeon consensus: Cementation techniques for total knee arthroplasty in orthopedic implant manufacturers’ guidelines lack consistency

Abstract

Aim: Given recent concerns regarding the influence of different cements and implants on the rate of aseptic failures in total knee arthroplasty (TKA), we wondered if cementation technique could play a role. The primary aim of this review was to collect and compare the surgeon education materials from eight orthopedic implant manufacturers to evaluate the manufacturers’ recommended cementation technique in TKA and identify if there was any consistency in these readily available guides as to the best practices of cementation of their implants. Materials and Methods: We reviewed contemporary surgeon education guidelines for all TKA systems available from eight manufacturers. Variables included: cement type, batches prepared, surface preparation prior to application, cleaning and/or drying the bone surface, mixing the cement, the waiting phase after the cement has been mixed prior to application, pressurizing the cement, location of cement application, and the curing time. Data were recorded and organized for qualitative comparisons. Results: We identified a total of 43 guides covering 38 implants from eight different manufacturers. There were 41 surgical technique guides and two general brochures regarding cementation techniques available from the manufacturers. Even within the manufacturers’ own guidelines for the different implants, there was a wide variety of differing guidelines on many aspects of the cementation technique. Conclusion: There is clearly no consensus for a preferred cementation technique both within and among manufacturers’ surgeon education materials regarding tibial baseplate cementation during TKA. Efforts may be needed to identify a best-practice cementation technique in an effort to reduce the number of TKA failures associated with aseptic loosening.

The Effect of Working Time and Application Technique on Cement Penetration into a Tibial Model

“…Another finding of this study was the increased penetration around the stem of the implant when the osteotome technique was employed. Previous authors describe a <1% rate of loosening when employing this technique [32]. This difference existed when compared with both gun and layered techniques and persisted with both early and late cementation.…”

“…This difference existed when compared with both gun and layered techniques and persisted with both early and late cementation. Again, some authors contend that cementation of the stem provides no benefit in resisting micromotion if penetration beneath the implant is adequate at 3-5 mm [30,32,33]. Furthermore, arguments have been made that full cementation may result in greater bone loss at revision and cause stress shielding.…”

No effect of fixation type on early and late mortality after total knee arthroplasty: a Dutch arthroplasty register study

“…The main limitation of this study was the retrospective design and that analyses were naturally limited to the data collected by the LROI, although all data were prospectively collected with a 96% completion rate of all arthroplasties performed in the Netherlands [26]. Furthermore, all cemented TKA were analysed as one group, while the manner of cementation varies between orthopaedic surgeons [13] as well as manufacture educational material [21]. However, as the effect of the manner of cementation and incidence of BCIS had not been determined to our best knowledge, it was justified to analyse the cemented prostheses as one group.…”

Does tibial design modification improve implant stability for total knee arthroplasty? An experimental cadaver study

“…Regarding cement application, however, there is some disagreement about the best approach. 11 - 13 Refsum et al 14 showed that in six out of ten cases, cement application was performed with a cement gun, and in four cases by finger-packing technique. The question of cement application to the undersurface of the prosthesis with or without cementation of the stem is still controversial.…”