Cemented Stems

Cory G. Couch

Robert T. Trousdale

Key Concepts

Cement-in-cement revision technique refers to a revision method in which a femoral component is removed from an intact cement mantle and a new femoral component is cemented back into the previous cement mantle.
The technique is predicated on the old cement mantle being well fixed at the bone-cement interface and the concept that new cement bonds effectively to the old cement.
The technique is only applicable to a modest number of revision scenarios, typically those in which a stem has debonded from the cement at the implant-cement interface, or situations in which for exposure or biomechanical reasons it is desirable to remove a smooth-surfaced femoral component from a well-fixed cement mantle by deliberately debonding it at the cement-implant interface during revision.
Reported results of the technique have been mostly favorable.

Indications

The main indication for cement-in-cement revision is a previously cemented femoral implant that must be removed but in which the cement-bone interface remains intact.
This technique improves exposure for acetabular revision and is ideal for a broken cemented stem, a monoblock cemented stem with damaged or incompatible head diameter, a stem that is loose at the cement implant interface, a cemented modular stem with damaged or incompatible taper, or component malposition (requiring change of stem offset, stem version or leg length).
The advantage of cement-in-cement revision is the potential to minimize blood loss, operative time, bone loss, and risk of fracture and femoral perforation. The technique can also improve acetabular exposure and usually allows early full weight bearing (Table 31.1).

Sterile Instruments and Implants

Routine hip retractors and system-specific revision hip instrumentation.
Cemented femoral component extraction system.
High-speed burr.
Revision cemented femoral component of choice (polished tapered stems work well for this technique).
Bone cement

Surgical Approaches

Positioning: lateral decubitus position.
Both the posterior and direct lateral approaches may be used. The senior author prefers the posterior approach as it is reproducible and may provide better access and visualization to the femoral canal.
The senior author reserves the anterolateral approach to patients with severe abductor damage seen at the time of exposure. The cement-in-cement technique is not typically considered compatible with extended greater trochanteric osteotomy.

Radiographic Evaluation—Evaluate Serial Radiographs of the Arthroplasty if Possible

Component fixation: Evaluate for radiolucencies at the bone-cement interface. Evaluation preoperatively on both anteroposterior and lateral radiographs is important. The cement mantle must be intact and well fixed to bone below the level of the lesser trochanter.
If the failure of the femoral component has occurred at the cement-bone interface, or if the patient has developed extensive radiolucencies around the cement mantle, then cement-in-cement revision is contraindicated.

Review prior operative reports