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Bone cement

Article  in  Journal of Clinical Orthopaedics and Trauma · December 2013

DOI: 10.1016/j.jcot.2013.11.005

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Review Article

Bone cement

Raju Vaishya (MS, MCh, FRCS)a,*, Mayank Chauhan (MS Orth)b,

Abhishek Vaish (MBBS)c
a
Prof, Senior Consultant, Department of Orthopaedic & Joint Replacement Surgery, Indraprastha Apollo Hospitals,
New Delhi, India
b
Orthopaedic Registrar, Department of Orthopaedic & Joint Replacement Surgery, Indraprastha Apollo Hospitals,
New Delhi, India
c
Post Graduate Student (Orthopaedics), Department of Orthopaedics, Sancheti Institute of Orthopaedics, Pune, India

article info abstract

Article history: The knowledge about the bone cement is of paramount importance to all Orthopaedic
Received 6 November 2013 surgeons. Although the bone cement had been the gold standard in the field of joint
Accepted 21 November 2013 replacement surgery, its use has somewhat decreased because of the advent of press-fit
Available online 15 December 2013 implants which encourages bone in growth. The shortcomings, side effects and toxicity
of the bone cement are being addressed recently. More research is needed and continues in
Keywords: the field of nanoparticle additives, enhanced boneecement interface etc.
Bone cement Copyright ª 2013, Delhi Orthopaedic Association. All rights reserved.
Joint replacement
Arthroplasty
Antibiotic
Viscosity

applications. CPCs are bio resorbable and biocompatible, but

1. Introduction are mainly used in cranial and maxillo-facial surgeries
because of their low mechanical strength.2
Polymethyl methacrylate (PMMA), is commonly known as Even though the uses and availability of various types of
bone cement, and is widely used for implant fixation in bone cement has greatly evolved over the past century, further
various Orthopaedic and trauma surgery. In reality, “cement” research still continues to develop its more clinical applications
is a misnomer because, the word cement is used to describe a and to reduce the adverse effects associated with their use.
substance that bonds two things together. However, PMMA
acts as a space-filler that creates a tight space which holds the
implant against the bone and thus acts as a ‘grout’.1 Bone
cements have no intrinsic adhesive properties, but they rely 2. Historical perspective
instead on close mechanical interlock between the irregular
bone surface and the prosthesis. Other types of commercially Themistokles Gluck (1870), had fixed a total knee prosthesis
available bone cement like calcium phosphate cements made of ivory using cement made of plaster and colophony.3
(CPCs) and Glass polyalkenoate (ionomer) cements (GPCs) are Otto Rohm and Kulzer were early pioneers who worked
successfully used in a variety of orthopaedic and dental extensively on the physical properties and uses of bone

* Corresponding author.
E-mail address: raju.vaishya@gmail.com (R. Vaishya).
0976-5662/$ e see front matter Copyright ª 2013, Delhi Orthopaedic Association. All rights reserved.
http://dx.doi.org/10.1016/j.jcot.2013.11.005
 Author's personal copy

158 j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 4 ( 2 0 1 3 ) 1 5 7 e1 6 3

cement. The era of modern PMMA bone cements comes from temperature dissipation via the large prosthesis surface and
the patent by Degussa and Kulzer (1943), who had described the flow of blood.8
the mechanism of polymerization of methyl methacrylate
(MMA) at room temperature if a co-initiator, such as a tertiary
aromatic amine, is added.4 3.1. Antibiotic bone cement
The first bone cement use in Orthopaedics is widely
credited to the famous English surgeon, John Charnley, who in Bone cement has proven particularly useful because specific
1958, used it for total hip arthroplasty.5 He had used cold- active substances, e.g. antibiotics, can be added to the powder
cured PMMA to attach an acrylic cup to the femoral head component. This makes bone cement a modern drug delivery
and to seat a metallic femoral prosthesis. This was a signifi- system that delivers the required drugs directly to the surgical
cant milestone in the advancement of Orthopaedic surgical site. The local active substance levels of bone cements are
procedures. Also, Charnley was the first to realize that PMMA significantly below the clinical routine dosages for systemic
easily could be used to fill the medullary canal and is easy to single injections. Research has shown that adding various types
blend with the bone morphology. of antibiotics to bone cement, in quantities less than 2 g per
In the 1970’s, the U.S. Food and Drug Administration (FDA) standard packet of bone cement, does not adversely affect some
approved bone cement for use in hip and knee prosthetic of the cement’s mechanical properties (compressive or dia-
fixation.6 Since then, while bone cement has become widely metrical tensile strengths), although quantities exceeding 2 g
used for fixation of prostheses to living bone, the trends of did weaken them.9 Various antibiotics have been successfully
bone cement usage have evolved. mixed and used with bone cements like Gentamycin, Tobra-
mycin, Erythromycin, Cefuroxime, Vancomycin, Colistin etc.
The basic requirement, being that the mixable antibiotic should
be heat resistant and should last for longer duration of time.
3. PMMA constituents Gentamycin, when used in combination with tobramycin,
shows a synergistic effect, with a 68% greater elution of
PMMA is an acrylic polymer that is formed by mixing two tobramycin (P ¼ 0.024), and 103% greater elution of vanco-
sterile components (Table 1): a liquid MMA monomer and a mycin from the bone cement (P ¼ 0.007), compared to controls
powered MMA-styrene co-polymer.7 When the two compo- containing only one antibiotic.10
nents are mixed, the liquid monomer polymerizes around the van Staden in his study reported that Bacteriocins may be a
pre polymerized powder particles to form hardened PMMA. In possible alternative to antibiotics incorporated into bone
the process, heat is generated, due to an exothermic reaction. cement. The in vitro results of the study showed that bacte-
PMMA, along with the presence of various additives, gives riocins incorporated into brushite cement did not significantly
the mixture a set of physical and chemical properties.3 alter the characteristics of the matrix and that the peptides
Exposure to light or high temperatures can cause premature were released in an active form. Finally it was shown that
polymerization of the liquid component. Hydroquinone nisin F-loaded brushite cement controlled S. aureus infection
therefore is added as a stabiliser or inhibitor to prevent pre- in mice.11
mature polymerization. An initiator, di-benzoyl peroxide Silver containing nanoparticles have also shown promise
(BPO), is added to the powder, and an accelerator, mostly N, N- as effective antibacterial agents which can be added to bone
dimethyl-p-toluidine (DmpT), is added to the liquid to cement.12 Vitamin E additives (10%) have shown a positive
encourage the polymer and monomer to polymerise at room effect on free radical oxidation and exothermic activity, with
temperature (cold curing cement). only modest reduction (<5%) in tensile strength.4
In order to make the cement radiopaque, a contrast agent Compared to intramuscular administration, systemic
is added. Commercially available cements use either zirco- concentration levels of Gentamycin are low with bone
nium dioxide (ZrO2) or barium sulphate (BaSO4). Zirconium cement, usual maximum level being <1 mg/ml (<10%). There
dioxide is one hundred times less soluble than barium sul- are no detectable systemic levels after seven days from
phate and has less effect on the mechanical properties of the administration. Gentamycin levels in urine after bone cement
cement. administration range from 10 mg/ml initially to 1e2 mg/ml after
During the exothermic free-radical polymerization pro- seven days.
cess, the cement heats up. This polymerization heat reaches Different bone cements have different chemical formula-
temperatures of around 82e86
C in the body. The cause of the tions, giving a range of antibiotic bone cements with varying
low polymerization temperature in the body is the relatively handling characteristics, which are suited to a broad range of
thin cement coating, which should not exceed 5 mm, and the clinical requirements and surgical techniques.

Table 1 e Constituents of bone cement.

Powder Liquid
I) Polymer: Polymethyl methacrylate/co-polymer (PMMA) I) Monomer: Methyl methacrylate (MMA)
II) Initiator: Benzoyl peroxide (BPO) II) Accelerator: N, N-Dimethyl para-toluidine (DMPT)/diMethyl
para-toluidine (DMpt)
III) Radio-opacifier: Barium sulphate (BaSO4)/Zirconia (ZrO2) III) Stabilizer: Hydroquinone
IV) Antibiotics (e.g. Gentamycin)
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3.2. Usage and properties Following introduction the implant must be firmly held in
position to avoid movement and pressurization must be
Since Charnley first began using acrylic bone cement in hip maintained until the cement finally hardens. Excess bone
arthroplasty, there have been a number of developments in cement must be removed before the cement has completely
the usage and properties of bone cement. hardened.

3.3. Curing process

4.2. Syringe application
The curing process is divided into 4 stages: a) mixing, b) sticky/
waiting, c) working, and d) hardening. The mixing can be done Gentamycin antibiotic bone cements may be applied using a
by hand or with the aid of centrifugation or vacuum suitable cement gun and syringe (Fig. 1). The surgeon should
technologies. use their experience to judge when the cement has reached an
Bone cements are heat sensitive. Any increase or decrease appropriate viscosity to be extruded. This will not occur until
in temperature (either ambient, and/or of the cement com- after the cement has formed dough. A small amount of
ponents and mixing equipment) from the recommended cement should be extruded from the syringe and visually
temperature of 73
F (23
C) affects the handling characteris- assessed to ensure that the surface of the cement appears dull
tics and setting time of the cement. Manual handling and body and excessive flow under gravity has ceased.
temperature reduces the final setting time. Variations in hu- Prior to extrusion, it is recommended that a cement
midity affect the cement handling characteristics and setting restrictor be inserted, at the required depth into, the prepared
time. It is recommended that the unopened cement compo- bone cavity.14 Introduction of bone cement into the prepared
nents are stored at 73
F (23
C) for a minimum of 24 h before cavity should be carried out in a retrograde fashion. Once the
use. Vacuum mixing of cement can also accelerate the setting cavity is filled it is advisable that adequate pressurization is
time of the cement. applied and maintained up to the point of hardening.
High viscosity cements are sometimes pre-chilled for use
with mixing systems for easier mixing and prolonged working
4.3. Vacuum mixing & delivery
phase. This will also increase the setting time. The relative
humidity might also influence the handling properties. That is
Vacuum mixing, which was adapted from the dental field, was
the reason why the working time and setting time of the
developed for bone cement in the early 1980s. Vacuum mixing
cement might vary in winter and summer.
reduces bone cement porosity and reduces monomer evapo-
Unlike the polymerization reaction of PMMA, calcium
ration and exposure in the operating room.
phosphate cements are hardened through a dissolution and
Mixing as well as collecting cement under vacuum yields a
precipitation process that produces hardening with entan-
homogenous mix without affecting viscosity or other prop-
glement of precipitated crystals.2
erties of the cement.15

4. Methods of application

Various methods exist for the application of cement into the

bone or joint surface.13

4.1. Digital

All antibiotic bone cements can be applied digitally. The

cement is mixed thoroughly but carefully to minimize the
entrapment of air. Once dough is formed the surgeon should
wait until the cement no longer adheres to the glove and the
surface has become dull as opposed to shiny. The cement can
then be taken into gloved hands and kneaded thoroughly. It is
vital that premature insertion of cement is avoided as this
may lead to a drop in the patient’s blood pressure. Impor-
tantly, this stage will occur at different times for different
cement types.
The time of cement application and prosthesis insertion is
at the discretion of the surgeon and will depend upon the
surgical procedure used. In general, implant insertion should
be delayed until the cement has developed a sufficient degree
of viscosity to resist excessive displacement by the implant.
However, implant insertion should not be delayed such that
there is a risk that the procedure cannot be completed due to
cement hardening. Fig. 1 e Powder and liquid components of bone cement.
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4.4. Pressurization

The pressure applied to the cement has to be larger than the

blood pressure so as not to be pushed out of the bone. Pressure
should be applied until the viscosity of the bone cement has
increased so it is high enough to resist blood pressure. Many
studies state that pressurization results in greater penetration
of the bone, improves boneecement interface and increases
fatigue strength of the cement. When pressurizing the cement
in the femur, a positive sign of pressurization is marrow
extrusion in the greater trochanter (the so-called sweating
trochanter sign).16 Fig. 3 e Distal centralizer.

4.5. Viscosity

Mixing together the powder and the liquid components marks

Thickness of the cement mantle around any shaft should
the start of the polymerization process. During the reaction,
be approximately 3 mm to provide sufficient mechanical
the cement viscosity increases, slowly at first, then later more
strength. Spacers on the acetabular cup will ensure an even
rapidly (Fig. 2). Studies have shown that high viscosity ce-
cement layer around the cup. The cement mantle should be
ments result in better prosthetic fixation, as compared to low
2e3 mm, yielding better stress distribution.
viscosity cements.17
The distal cement centralizer is widely used and is
Bone cements may be divided into three kinds: low, me-
assumed to be valuable in affecting the quality of cemented
dium and high viscosity.
total hip replacement. The literature suggests that the use of
Low viscosity: these cements have a long-lasting liquid, or
the distal centralizer improves the quality of the distal mantle
mixing phase, which makes for a short working phase. As a
as well as improves stem position.19 However, some studies
consequence, application of low viscosity cements requires
dispute the same.18
strict adherence to application times.
High viscosity: these cements have a short mixing phase
and lose their stickiness quickly. This makes for a longer 4.7. Cement restrictors
working phase, giving the surgeon more time for application.
Ideal viscosity will be high enough to avoid any cement The use of intramedullary plugs in cemented total joint
mixing with blood or fat/bony material from the implantation arthroplasty is now considered a routine practice by most
region yet low enough to penetrate the bone adequately. surgeons. In order to achieve good filling and pressurization in
hip, a small piece of bone or a cement restrictor may be used
4.6. Stem centralizer to plug the shaft. The restrictor should be placed no more than
2 cm distal to tip of the stem.
Femoral stem centralizers were originally designed for double The primary goal of plugging the intramedullary canal
tapered, straight stems.18 A stem centralizer (Fig. 3) guides the during total hip arthroplasty is to increase penetration of
femoral prosthesis to a neutral position within the cement cement into the cancellous bone proximal to the intra-
and guarantees an even cement layer between the bone and medullary plug. This recalls in greater penetration and may
prosthesis.19 enhance prosthetic stability.

5. Bone bed preparation

5.1. Micro-interlock

The concept of micro-interlock is a positive contribution to the

quality of fixations. The interface strength is not only affected
by the degree of cement penetration but also by the quality of
the cancellous framework. The addition of hydroxyapatite
(HA) enhances the connection to the bone since HA is the
main inorganic constituent of bone tissue, although this
compromises the mechanical strength of the cement.20
There are a number of essential prerequisites for success-
ful micro-interlock:

1. Thoroughly cleaned bone bed, brush and lavage before

Fig. 2 e Mixing of bone cement. applying the cement.
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j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 4 ( 2 0 1 3 ) 1 5 7 e1 6 3 161

2. Injecting the cement until it is of high viscosity- It prevents

the blood from penetrating into the cement and thereby
weakening it.
3. Pressurize the cement by using a cement gun and sealing
off the bone cavity.

Careful preparation of the bone cavity and bone bed with

high-pressure pulse lavage and brushing is essential for
achieving an effective micro-interlock between the bone and
the cement.

5.2. Reaming

The bone cavity should be shaped to provide an even cement

layer between the bone and prosthesis. Size of reaming should
be determined at preoperative planning.

5.3. Brushing

Mechanical cleaning with a brush is recommended. Acci-

dental introduction of blood and tissue debris into the cement
may cause laminations, which can lower the effective
strength of the bone cement. Acetabular and femoral brushes
are used to remove soft tissue and loose cancellous bone from Fig. 5 e Cemented acetabular component.
the cavity.
Anchorage holes increase the contact area between bone and
cement, providing for better fixation (Fig. 5).
5.4. Pulse lavage

Using high-pressure pulse lavage (Fig. 4) to remove remaining

bone particles and debris in a joint arthroplasty produces a 6. Evolution of cementing techniques
clean surface. The risk of blood lamination is reduced and the
mechanical strength of the cement is increased. Micro- Overall, advancements in cementing can be classified to have
interlock between the bone and the cement is achieved by occurred from ‘first generation’ to ‘third generation tech-
high-pressure pulse lavage repeatedly.21 niques’, with changes occurring in bone bed preparation,
A study concluded that meticulous high volume; high- cement preparation and cement delivery.23,24
pressure pulsatile lavage reduces both pulmonary physiolog-
ical derangements and fat emboli.22 6.1. First generation cementing technique

5.5. Anchorage holes in the acetabulum It involved the hand mixing of cement in bowels. There was
only a minimal preparation of the femoral canal and cancel-
The anchorage holes are made in order to remove as little lous bone was left in-situ. The canal was irrigated and suc-
bone as possible and they may be drilled and/or impacted. tioned prior to the digital application of cement. The
prosthesis was then inserted into the femoral canal. During
the 1980’s these techniques were refined. Steps were taken to
reduce the porosity of the cement and thereby increase the
fatigue life. Pressurization of the cement was introduced to
improve osseo-integration of the cement and the importance
of a good cement mantle around the prosthesis was more
clearly understood.

6.2. Second generation cementing techniques

All cancellous bone is removed as near to the endosteal sur-

face and distal cement restrictor was also used. There is pul-
satile irrigation, packing and drying of the femoral canal
followed by retrograde insertion of cement with a cement gun.
The prosthesis is again positioned manually.25 Further
improvement lead to the development of third generation
Fig. 4 e Pulse lavage. cementing techniques.
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162 j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 4 ( 2 0 1 3 ) 1 5 7 e1 6 3

6.3. Third generation cementing techniques femoral cement implantation, insertion of the prosthesis
or joint reduction. It is an important cause of intraoperative
Cement is now prepared using a vacuum-centrifugation, mortality and morbidity in patients undergoing cemented
which further reduces porosity. The femoral canal is irri- hip arthroplasty and may also be seen in the postoperative
gated with pulsatile lavage and then packed with adrenaline period in a milder form causing hypoxia and confusion.
soaked swabs. After insertion of the cement in a retrograde  Hypoxaemia.
fashion, the cement is pressurised. Finally the prosthesis is  Cardiac arrhythmia.
inserted using distal and proximal centralizers to ensure an  Bronchospasm.
even cement mantle (4th generation).  Adverse tissue reaction.
 Haematuria.
 Dysuria.
 Bladder fistula.
7. Caution and adverse effects  Local neuropathy.
 Local vascular erosion and occlusion.
Hypotensive episodes and cardiac arrest have been reported  Transitory worsening of pain due to heat released during
during cement insertion.26 polymerization.
Pressurization and thorough cleaning of the bone with  Delayed sciatic nerve entrapment due to extrusion of the
expulsion of bone marrow has been associated with the bone cement beyond the region of its intended application.
occurrence of pulmonary embolisms, and this risk has been  Intestinal obstruction because of adhesions and stricture
found to be increased in patients with highly osteoporotic of the ileum due to the heat released during cement
bone and patients diagnosed with femoral neck fracture. polymerization.
Reaming of the marrow cavity can have similar effects on
mean arterial pressure as the introduction of the bone
cement. Marrow cavities should be vented when the cement is
introduced digitally. The premature insertion of bone cement 8. Drawbacks of bone cement
may lead to a drop in blood pressure, which has been linked to
the availability of methyl methacrylate at the surface of the One of the major drawbacks of bone cement in joint replace-
product,27 although this has not been proven. This drop in ment is cement fragmentation and foreign body reaction to
blood pressure, on top of hypotension induced either acci- wear debris, resulting in prosthetic loosening and peri-
dentally or intentionally, can lead to cardiac arrhythmias or to prosthetic osteolysis. The production of wear particles from
an ischaemic myocardium. However, according to a report, roughened metallic surfaces and from the PMMA cement
the possible risk of death associated with the use of cemented promotes local inflammatory activity, resulting in chronic
implant is confined to early postoperative and perioperative complications to hip replacements. Histologically, a layer of
period.28 synovial like cells which line the bone cement interface sup-
The hypotensive effects of methyl methacrylate are ported by a stroma containing macrophages and wear parti-
potentiated if the patient is suffering from hypovolaemia. cles, has been described in loose prostheses.31 A third of
The most frequent adverse reactions reported with acrylic dense fibrous tissue contains polymethyl methacrylate, poly-
bone cements are: ethylene and metallic debris. Activated macrophages express
cytokines including interleukin-1, interleukin-6 and tumour
 Transitory fall in blood pressure. necrosis factor alpha, which mediate periprosthetic osteolysis.
 Elevated serum gamma-glutamyl-transpeptidase (GGTP) Bone cement generates heat as it cures and contracts and
upto 10 days post-operation. later expands due to water absorption. It is neither osteoin-
 Thrombophlebitis. ductive nor osteoconductive and does not remodel.
 Loosening or displacement of the prosthesis. The monomer is toxic and there is a potential for allergic
 Superficial or deep wound infection. reactions to cement constituents.
 Trochanteric bursitis.
 Short-term cardiac conduction irregularities.
 Heterotopic new bone formation. 9. Conclusion
 Trochanteric separation.
The knowledge about the bone cement is of paramount
importance to all Orthopaedic surgeons. Although the bone
7.1. Other known adverse effects29,30 cement had been the gold standard in the field of joint
replacement surgery, its use has somewhat decreased
 BCIS (Bone cement implantation syndrome) is character- because of the advent of press-fit implants which encourage
ized by a number of clinical features that may include bone in growth. The shortcomings, side effects and toxicity of
hypoxia, hypotension, cardiac arrhythmias, increased the bone cement are being addressed recently. More research
pulmonary vascular resistance (PVR) and cardiac arrest. It is needed and continues in the field of nanoparticle additives,
is most commonly associated with, but is not restricted to, enhanced bone cement interface and other developments in
hip arthroplasty.29 It usually occurs at one of the five stages quest for improving the quality and eliminating or reducing
in the surgical procedure; femoral reaming, acetabular or undesired side effects of bone cement.
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j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 4 ( 2 0 1 3 ) 1 5 7 e1 6 3 163

16. Available at: http://www.bonecement.com/cementing-

Conflicts of interest techniques/pressurization.
17. Mjöberg B, Rydholm A, Selvik G, Onnerfält R. Low- versus
No benefits in any form have been received or will be received high-viscosity bone cement. Fixation of hip prostheses
from a commercial party related directly or indirectly to the analyzed by roentgen stereophotogrammetry. Acta Orthop
Scand. 1987 Apr;58(2):106e108.
subject of this article.
18. Bell CA, Pilot P, van den Boogaart M, Verburg AD. Effect of a
distal centralizer on the positioning of an anatomical stem.
Acta Orthop Belg. 2009 Feb;75(1):41e44.
19. Hanson PB, Walker RH. Total hip arthroplasty cemented
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