3. Year Development
1870 Themistokles Gluck
First surgeon to implant a total knee prosthesis made
of ivory in Germany
The stems were fixedwith cement mixed of plaster and
colophony
1930’s Otto Rohm
Synthesized a group of thermoplastics, i.e., acrylic
polymers
These polymers replaced hard rubber as the base
materials for dentures
1950’s –
1960’s Sir John Charnley
Developed the modern cementing technique
Used cold-cured PMMA to attach an acrylic cup to the
femoral head and to seat a me-
tallic femoral prosthesis;
First to realize that PMMA could be used to fillthe
medullary canal and to blend with the
bone morphology
4. 1970’s U.S. FDA
Approved bone cement for use in hip and
knee prosthetic fixation
Cement was the preferred technique for total
joint fixation
Cementless fixationtechniques were
1980’s preferred
1990’s -
Present Hybrid systems are the preferred technique
2003 U.S. FDA
Cleared the firstantibiotic bone cement
preparation
6. Types of Bone Cement :
•Low viscosity cements – These cements remain in a runny state for a much
longer period of time as compared to medium or high viscosity cements.
Typically they have a long waiting phase. The true working time in which the
cement can be picked up with a gloved hand usually is short, and the setting time
can vary.
•Medium viscosity cements – These types of cements can offer versatility
for various types of procedures. Medium viscosity cements are both low and high
in viscosity, depending on the time at which the cement is delivered. Medium
viscosity cements are considered to be dual phase cements. They begin in a low
viscosity state while being mixed, which allows for the easy and homogenous
mixing of the powder and the liquid.
•High viscosity cements – These types of cements primarily are comprised
of PMMA with no methylmethacrylate-styrene-copolymer content; they have no
runny state at all. Immediately after mixing, the cement is doughy and ready to
apply by hand to the implant surface. The working time for high viscosity
cements needs to be closely monitored; it is not always easy to determine the
end of the working time before it is too stiff to interdigitate with the bone.
7. INDICATIONS FOR
THE USE OF BONE CEMENT :
PMMA bone cement is intended for use in arthroplastic procedures of
the hip, knee, and other joints for the fixationof polymer or metallic prosthetic
implants to living bone.
Other indications include:
•Joint deterioration due to rheumatoid arthritis, osteoarthritis, or traumatic
arthritis
•Avascular necrosis
•Sickle cell anemia
•Collagen disease
•Severe joint destruction secondary to trauma or other conditions
•Revision of a previous arthroplasty
•Fixation of pathological fractures where loss of bone substance or
recalcitrance of the fracture renders more conventional procedures ineffective
8. CONTRAINDICATIONS
TO THE USE OF BONE CEMENT :
PMMA bone cement is contraindicated in the presence of active or
incompletely treated infection, at the site where the bone cement is to be applied.
The use of PMMA is also contraindication for patients who:
•Are pregnant or nursing
•Are allergic to the antibiotic or any of the other components of PMMA
•Have a history of hypersensitivity or serious toxic reactions to aminoglycosides
e.g., gentamicin or vancomycin, due to the known cross-sensitivity of patients
to drugs in this class.
•Have an active infectious arthritis of the joint or joints to be replaced or
a history of such an infection
•Have a loss of musculature or have neuromuscular compromise in the affected limb
this would render the procedure unjustifiable
•Have myasthenia gravis
•Have metabolic disorders which may impair bone formation
•Are hypotensive
•Have renal impairment
•Have congestive heart failure
9. Processing and Handling
of Bone Cement :
Once the liquid and powder components are
mixed during the routine application of
acrylic bone cement in a surgical procedure,
the polymerization process is divided into
four phases:
1 )mixing
2) Waiting
3)Working
and
4)hardening
10. 1 ) Mixing Phase.
The mixing phase starts with the addition of the liquid to the powder
and ends when the dough is homogenous and stirring becomes
effortless.
When the liquid and powder components of the cement are mixed
together, the liquid wets the surface of the prepolymerized powder.
Because PMMA is a polymer that dissolves in its monomer (which is not
the case for all polymers),
the prepolymerized beads swell and some of them dissolve
completely during mixing. This dissolution results in a substantial
increase in the viscosity of the mixture; however, at this stage the
viscosity is still relatively low, compared with the later phases of
polymerization. At the end of the mixing phase, the mixture is a
homogenous mass and the cement is sticky and has a consistency
similar to toothpaste.
11. 2 ) Waiting Phase.
The mixing phase is followed by a waiting period to
allow further swelling of the beads and to permit
polymerization to proceed. This leads to an increase in
the viscosity of the mixture. During this phase,
the cement turns into sticky dough. This dough is subsequently tested
with gloved fingersevery 5 seconds,
using a different part of the glove on another
part of the cement surface on each testing occasion.
This process provides an indication of the end of the waiting phase
when the cement is neither “sticky” nor “hairy.”
12. 3 ) Working Phase.
The beginning of the working phase occurs when the cement is no longer sticky, but is
of sufficiently low viscosity to enable the surgeon to apply the cement. During this
period, polymerization continues and the viscosity continues to increase; in addition,
the reaction exotherm associated with polymerization leads to the generation of heat
in the cement. In turn, this heat causes thermal expansion of the cement, while there
is a competing volumetric shrinkage of the cement as the monomer converts to the
denser polymer. During the working phase, the viscosity of the cement must be closely
monitored because with a very low viscosity, the cement would not be able to
withstand
bleeding pressure. This would result in blood lamination in the cement, which causes
the cement to weaken. This phase is completed when the cement does not join
without folds during continuous kneading by hand; at this point, an implant can no
longer be inserted (Figure ). Therefore, the prosthesis must be implanted before the
end of the working phase.
14. 4) Hardening or Setting phase.
The last phase is the hardening or the setting period, in
which the polymerization stops and the cement cures to a
hard consistency. As noted, the prostheses must be in
place prior to this phase. The temperature of the cement
continues to be elevated, but then slowly decreases to
body temperature. During this phase, the cement
continues to undergo both volumetric and thermal
shrinkage as it cools to body temperature. The cement is
ready for implantation when two cement balls are
touched to each other and they stick together; if they do
not stick together, the cement is in the curing stage and
should not be used to implant the prosthesis. If
implantation is completed with the cement in the curing
stage, it could result in the cement delaminating or
separating from the bone and/or the prosthesis.
15. In general, all bone cements have definate
doughing, working, and setting time:
•Dough time:
starts from beginning of mixing and ends at the point when the cement will
not stick to unpowdered surgical gloves.
This occurs approximately 2-3 minutes after the beginning of mixing for most
PMMA cements.
•Working time:
this is the time from the end of dough time until the cement is too stiff to
manipulate, usually about 5-8 minutes.
•Setting time:
from the beginning of mixing until the time at which the exothermic reaction
heats the cement to a temperature
that is exactly halfway between the ambient and maximum temperature
(i.e., 50% of its maximum value) and is the dough + working times; usually
about 8-10 minutes.
16. Factors that Affect
Bone Cement Preparation :
When preparing PMMA bone cement,
only the mixing phase is considered to be constant;
the waiting, working, and hardening phases are dependent on several factors,
as noted below.
•The ambient temperature.
The higher the temperature, the shorter the phases;
the colder the temperature, the longer the phases.
•The mixing process.
Mixing cement too quickly or too aggressively can hasten the polymerization reaction;
this will generate an increased amount of energy
In general, the lower the heat of polymerization, the longer the setting time,
and the greater the heat of polymerization, the shorter the setting time.
•The type of cement. The various types of cement have different setting times.
•The powder to liquid ratio. Each type of bone cement is packaged with
the exact amounts of powder and liquid required to produce a consistent end product.
If more liquid, or less powder, than required is used, setting time will be prolonged;
on the other hand, if less liquid, or more powder is used, setting time will be shortened.
17. Bone Cement Additives
These additives include
nanoparticles of magnesium oxide (MgO) and
barium sulfate (BaSO4) as well as
multi-walled carbon nanotubes to slow down setting time.
Also nanoparticles of gold (Au) and porous pure titanium (pTi) are used to
increase cement strength.
Antibiotic :
Several factors influence the choice of antibiotic to be added to the bone
cement; the antibiotic must:
be able to withstand the exothermic temperature of polymerization;
be available as a powder;
have a low incidence of allergy; and
be able to elute from the cement over an appropriate time period.
18. antibiotics commonly used as
additives for PMMA bone cement
include vancomycin, gentamycin,
and meropenem, in addition to
tobramycin. Also, successful non-
antibiotic bactericides that have
been used as bone ce-ment
additives include quaternary
ammonium compounds such as
benzalconium chloride and cetyl
pyridinium chloride.35
19. Mixing Techniques :
Bone cement mixing technique classifications are briefly described below.
As always, with any cement mixing system, it is important to follow
the manufacturer’s instructions for use.
•Bag or hand mixing. Cement mixing techniques originally began as bag or hand mixing
n this method, the liquid was injected into a powder bag and
mixed by kneading it into low viscosity cement.
•Open bowl mixing. The next mixing technique was open bowl mixing.
The liquid and powder were poured together into a plastic or stainless
bowl and then mixed with a spatula.
This produced a cement of unpredictable quality, with high porosity,
due to air-filledspaces between the particles;
air trapped between lumps of mixing material just before the mixture becomes liquid;
and the air introduced by the stirring during hand spatulation.
This method also exposed the OR staff to noxious fumes.
The harmful effects of these fumes will be discussed in greater detail later.
•Closed bowl mixing (see Figure ). Subsequently,
the closed bowl technique was developed to reduce personnel exposure to the harmful
noxious PMMA fumes. This technique was the early paddle mixing system,
which evacuated the fumes by connection to the standard wall suction.
20.
21. Centrifugation after mixing. Immediate centrifugation of the
cement mixture after the mixing process reduces the size of any entrapped
air bubbles and, therefore, the porosity of the bone cement by spinning the
powder and liquid together. This reduction in porosity has been shown to
increase the compressive strength and handling properties of centrifuged cement
substantially when compared to manually mixed specimens.
The steps for the centrifugation of bone cement are as follows:
●Chill the liquid monomer to negate the shortening effect of
centrifugation on setting time.
●Mix the powder and the chilled liquid together.
●Introduce the resulting low-viscosity cement mixture into a cement syringe.
●Place the syringe in the centrifuge.
●Spin at high speed for a short period of time.
22. •Vacuum mixing (see Figure) Vacuum mixing was
the next development for mixing bone cement.
Today, most operating rooms mix bone cement under a partial vacuum,
where the cement is mixed under ideal conditions.
This results in a smaller amount of air becoming entrapped in the cement during mixing.
Vacuum mixing systems may mix the cement in a cement syringe,
in a bowl, or in a cement cartridge;
the system remains closed up until cement
delivery. All of these systems consist of an enclosed chamber
connected to a vacuum source, such as wall suction or a dedicated
vacuum pump; the vacuum source creates a partial vacuum during mixing.
All ingredients are added and mixed while the system is closed.
23. With any type of vacuum mixing system,
the components are added and mixed while the system is closed,
following the same general procedure:
●Wet the powder with the monomer.
●Apply the vacuum while the mixing continues according
to the manufacturer’s written instructions
The entrapped air bubbles will be drawn off via the partial vacuum,
thus reducing the porosity and
● thereby increasing the fatigue strength of the cement.
●The cement is then hand-packed or transferred to
a cartridge with a spatula and a funnel.
24. •High vacuum mixing. The next development in the cement
mixing process is high vacuum mixing.
A pump is used to create an ideal vacuum of 20 - 22 millimeters of mercury.
Paddle mixing is perfected in order to evacuate more air
from the cement by utilizing an ideal surface area and
ensuring inclusion of all powder and liquid.
The combination of a closed vacuum system and
carbon of a filterevacuates the harmful fumes.
Also, this type of system allows for
automatic transfer of cement into the cartridge while under vacuum.
•Cartridge mixing and delivery (see Figure ).
The latest advancement in bone cement mixing technique is a simple,
universal power mixer that quickly mixes and then mechanically injects
all types of bone cement. This type of device reduces mix times,
as it requires fewer steps to load, mix, and transfer the cement.
The rotary hand piece reduces variability,
which results in consistent mix times; a built-in charcoal filterreduces harmful fumes.
26. Application Techniques :
The methods for application
of bone cement include:
hand packing, injection, and gun pressurization; these are outlined below briefly
•Hand packing. The original method of cement application was hand packing,
where the femoral canal was packed either by the hand or finger
The. proximal end was packed with cement by pressing with the fingersor thumbs
; this pressurization forced the cement into the bone interstices
. Commonly, in total knee arthroplasty, cementing is hand packed since
the surfaces are readily visualized, which facilitates hand packing.
•Syringe injection. After hand packing, syringes are used to apply, or to inject,
the cement. Syringes are the predecessors to today’s gun pressurization devices.
•Injection with hand pressurization. With hand pressurization,
the proximal end is pressurized by pressing with the fingersor thumbs;
this pressurization forces the cement into the bone interstices.
•Injection with gun pressurization. The latest development in bone cement
application methods is the gun pressurization device.
Injection with gun pressurization offers a mechanical advantage that allows the surgeon
to force more cement into the interstices at a greater rate of pressurization.
Various pressurization tips allow more cement to be forced tightly into the bone,
while preventing overflow.
27. Factors that Weaken Bone Cement :
• First, intrusion of foreign materials can weaken the cement.
Often the word “contamination” is used to describe the presence
of unwanted matter in bone cement; however, in the
perioperative setting, typically the word “contamination” is
associated with pathogenic invasion. Therefore, the word
“intrusion” is better used in describing the effects that water,
saline, blood, bone chips, or fat have on the setting time and the
integrity of the hardened cement. Either a prolonged or a
reduced setting time depends on the type and the volume of
unwanted material that is introduced
• The second factor that can affect the longevity of the
attachment achieved by bone cement is the viscosity of the
polymerizing mix at the time it is introduced into the bone.
• Optimum viscosity helps the cement penetrate
the bone for good attachment of the prosthesis.
28. The specific hazards associated with
bone cement and
safety precautions are described below :
Health Hazards
1 ) Occupational hazards for surgical team OR staff :
• Excessive exposure to vapors can produce eye or respiratory
tract irritation
• Exposure to high concentrations of the vapor may cause headache,
dizziness, dyspnea, generalized erythroderma, and at very high levels,
drowsiness and even loss of consciousness.
• Exposure to the liquid can cause considerable
irritation or burns to the eyes;
• skin contact with the liquid monomer
may produce irritation or burns.
• Soft contact lenses are very permeable and should not be worn
where methyl methacrylate is being mixed, because the lenses are
subject to pitting and penetration by the vapors.
29. 2 ) Health hazards for patients :
transitory hypotension,
cardiac arrest,
cerebrovascular accident,
pulmonary embolus,
thrombophlebitis,
and hypersensitivity reactions;
while uncommon, cardiac arrest
and death have occurred after application of bone cement
Bone cement implantation syndrome (BCIS) is a well-recognized complex of
sudden physiologic changes that occur within minutes of the implantation
of methyl methacrylate bone cement to secure a prosthetic component into the bone
30. Signs and symptoms of
bone cement implantation syndrome
may include one or more symptoms,
including but not limited to:
• hypotension
• pulmonary hypertension
• increased central venous pressure
• pulmonary edema
• bronchoconstriction
• anoxia or hypoxemia
• decreased partial end tidal carbon dioxide
• cardiac dysrhythmia or arrhythmia
• cardiogenic shock
• transient decrease in arterial oxygen tension
• hypothermia
• thrombocytopenia
• cardiac arrest
• sudden death
31. Factors that increase a patient’s risk for BCIS include:
● Elderly patients with underlying:
• cardiovascular disease and who are undergoing cemented
arthroplasty for re-pair of a fracture
• severe osteoporosis
• malignancies especially involving the femur
• pulmonary disease
• Patients with intertrochanteric or pathologic fractures
• Patients who have pacemakers; who take sympathetic blockade medication;
are hypotensive or have inadequate volume replacement;
have a patent foramen ovale;
are hemodynamically unstable at the time of cementing and prosthesis insertion;
and have large femoral canals (e.g., mm or larger) requiring insertion of
a long-stem femoral component
32. Measures to Reduce the Risk of BCIS :
• using invasive hemodynamic monitoring when pre-existing cardiopulmonary
problems exist and during cementing
• maintaining a high level of arterial oxygenation and increasing inspired
oxygen concentrationby administering 100% oxygen during the procedure
• decreasing the concentration of a volatile agent (when using general anesthesia)
prior to insertion of the prosthesis
• maintaining normovolemia intraoperatively, especially at the time of cementing
and insertion of the prosthesis
• placing a venting hole into the femur, especially if using a long-stem prosthesis
• avoiding bilateral hip replacements with cemented prostheses
if cardiopulmonary dysfunction is present
• using a noncemented prosthesis, especially if the patient’s mean arterial pressure
decreases 20% to 30% below baseline during canal reaming or plugging
• performing thorough, pulsatile, high-pressure, high-volume lavage and brushing
followed by drying of the intramedullary canal of the femoral shaft
33. • using a cement restrictor combined with
other methods to reduce
intramedullary pressures
• using a low viscosity cement
• mixing the bone cement in a vacuum
• working the cement before insertion to
remove volatile vasodilator compounds
• using a cement gun to apply the cement
under sustained low pressure
• using a retrograde cement gun
technique for cement insertion
• using a vacuum tube along the linea
aspera to drain the proximal femur,
which reduces
• high intramedullary pressure during
cement and prosthesis insertion
introducing the prosthesis stem slowly
into the cemented femoral canal,
thereby reducing pressurization
34. Emergency First Aid Procedures :
Emergency firstaid procedures for exposure to PMMA bone cement include:59
•In the event of an emergency, institute firstaid procedures and
send for firstaid or medical assistance.
•Eye exposure – if methyl methacrylate gets into the eyes,
immediately wash the eyes with
large amounts of water, lifting both the upper and lower lids occasionally.
Get medical attention as soon as possible.
Contact lenses should not be worn when working with this chemical.
•Skin exposure – if the skin is exposed to methyl methacrylate, immediately flush
the contaminated skin with water. If methyl methacrylate soaks through the clothing,
remove the clothing immediately and flushthe skin with water.
Medical attention should be sought if the skin is irritated.
•Breathing – if a person breathes in large amounts of methyl methacrylate,
he/she should be moved to fresh air immediately. If breathing has ceased,
perform artificialrespiration. Keep the affected person warm and at rest.
Get medical attention as soon as possible.
Properly trained individuals may assist the affected person
by administering 100% oxygen.
35. • Swallowing – when methyl methacrylate has been swallowed, get
medicalattention immediately. If medical attention is not
immediately available, induce vomiting in the affected person (if
he/she is conscious) by having him/her touch
the back of the throat with his/her fingeror by giving him/her
syrup of ipecac as directed on the package. Do not induce
vomiting if the person is unconscious.
• Rescue – Move the affected person from the hazardous
environment. If the exposed person has been overcome, notify
someone else and implement
the established emergency rescue procedures.
Personnel should understand the facility’s rescue procedures and
know the locations of rescue equipment before the need arises.
