Cemented femoral stem fixation through the anterior approach has fewer early complications than cementless fixation

Aims To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications? Methods A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016 and 2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 years (70 to 86) in the cementless group and 76 years (52 to 94) in the cemented group, with 239 (70%) females in the whole series. Femoral complications were compared between the two groups. Mean follow-up was 1.5 years (0.1 to 4.4) for patients in the cementless group and 1.3 years (0.0 to 3.9) for patients in the cemented group. Results The cementless group had a higher rate of femoral complications (8 vs 0; p = 0.011). There were two loose stems and six fractures, all requiring revision. Fractures occurred a mean 14.5 days (2 to 31) postoperatively and loosening at 189 days and 422 days postoperatively. Femoral cementing can be done using the DA approach safely and reduces the number of complications compared with a contemporary cementless series. Conclusion A higher rate of early fractures and loosening occurred with cementless stems. This was not observed in our cemented stem cohort and cementing was safely accomplished through the DA approach. The modern femoral cementing process with the DA approach does not add to surgical complexity or time, has fewer early complications, and is a safer option for older patients compared to cementless femoral arthroplasties. Cite this article: Bone Joint J 2021;103-B(7 Supple B):33–37.

Minimum ten-year outcome of a triple-tapered femoral stem implanted with line-to-line cementing technique

Background A triple-tapered polished femoral stem was implanted with line-to-line cementing technique. The purpose of this study was to determine the survivorship, loosening rate, stem subsidence, radiologic changes and clinical outcomes in the minimum 10-year follow-up. Methods This was a retrospective study done in three institutes. Finally, 118 hips in 97 patients could be followed-up at the mean follow-up period of 126.3 months. The survivorship, radiological and clinical outcomes were investigated. Results Radiologically, 107 hips (90.7%) were categorized to Barrack cementing grade A, and 108 stems (91.5%) were inserted in neutral position. All hips were not loose and were not revised due to any reason. Survival with revision for any reason as the endpoint was 100% after 10 years. At the last follow-up, the mean subsidence was 0.43 mm, and the subsidence was less than 1 mm in 110 hips (93.2%). JOA hip score improved from 42.7 ± 8.9 points preoperatively to 92.8 ± 6.8 points at the last follow-up. No patient complained thigh pain. Conclusions Line-to-line cementing technique with use of a triple-tapered polished stem was effective to achieve good cementation quality and centralization of the stem. The subsidence was small, and the minimum 10-year results were excellent without any failures related to the stem. Trial registration Retrospectively registered.

Application of Key Technique in Splitter Wellhead Cementing Enabled Successful and Safe Operations

This paper describes the application of key technique for splitter wellhead cementing of top-hole section in conductor-sharing wells in dozens of development wells in offshore Malaysia. Its objective is to elaborate on the challenges faced during the well planning phase, methodology of cementing technique, cementing slurry design as well as solutions outcome and lessons learnt. Limitations of current software in the industry to simulate the conductor-sharing well cementation and approaches to maneuver through these limitations are also discussed. During the well planning phase, cementing technique to address the risks associated with splitter wellhead cementing such as accidental cementation of dummy string, poor cement coverage in shared conductor, and losses uncertainties were analyzed. The cementing execution results of first batch of wells are examined, i.e. pressure profile, cement returns as well as opportunities for improvement were documented and translated into recommendations leading to eventual success for future well design. The cement slurry design for each casing in the splitter wellhead are also established based on its associated job objectives which is based on the unique approach in splitter wellhead cementing. The establishment of key cementing technique for such an unconventional well construction technology is important in order to ensure continuous success both in cement placement as well as cement slurry design. The best practices are currently being replicated by other major operators in Malaysia for all splitter wellhead cement design. The learnings from the technique are incorporated into the technical standard of Malaysia operator as well to serve as a specific mandated requirement for future operations. An integrated study of wellhead design, drilling practices and cementing technologies enabled a novel methodology to assure long term zonal isolation for the wells and innovation in the cementing approach enable cost savings for the operator as the wells can be drilled in a safe, efficient and cheaper way.

Innovative and Unconventional Approach to Cementing A Ballooning Well Leading to Good Zonal Isolation

Good cement bond log and sufficient zonal isolation are important aspects of production wells. Proper cement design and displacement are essential to ensure the cement objectives are met. Well A is one of four development wells, located in East Malaysia. The well was a gas producer, therefore good zonal isolation at the gas intervals are of paramount importance. Coupled with high inclination and formation with narrow pore pressure and fracture pressure margin, ballooning condition was encountered while drilling the reservoir section. These challenging conditions push the boundary of conventional cementing design further to implementation of unique and novel cementing approach to ensure no losses, minimal mud contamination with cement slurry and ultimately produce good zonal isolation. This unexpected conditions of the well lead to re-designing the cement slurry and revamping the placement procedure for the 7" liner across production zone. Operator’s limited experience with cementing in ballooning conditions hampered any reference which could be useful for the job design. Required formation permeability, porosity data, mud flowback volume and duration of mud flowback at static condition were carefully assessed and taken into consideration in the cementing job design and pumping program. Based on the data gathered, an unconventional cement placement technique with specialized spacer and slurry design were proposed Well A, instead of complex back-pressure application technique in order to meet all required cementing objectives. The cementing job was executed as per plan and no losses were observed during the entire cement job. Cement evaluation through cement bond logs indicated that enough isolations across the hydrocarbons zones of interest were obtained. Moreover, cement bond logs also showed good zonal isolation were also attained above and below perforation intervals showing very little contamination of mud backflow into the cement slurry. The cementing technique used proved to be relatively simpler and cheaper as it requires no additional equipment to rig up to execute compared to complex back-pressure technique which done incorrectly may lead to losses or remedial cementing. The successful cementing operation showcased that the planned cementing technique and slurry design were effective for the cementing of abnormal well conditions. This success also highlighted the importance of job pre-planning and necessity to acquire all required data prior to actual operation. The job technique and design was replicated in subsequent wells which had similar well ballooning condition and resulted in great success.

Minimum Ten-Year Outcome of a Triple-Tapered Femoral Stem Implanted With Line-To-Line Cementing Technique

Background A triple-tapered polished femoral stem was implanted with line-to-line cementing technique. The purpose of this study was to determine the survivorship, loosening rate, stem subsidence, radiologic changes and clinical outcomes in the minimum ten-year follow-up. Methods This was a retrospective study done in three institutes. Finally, 118 hips in 97 patients could be followed-up at the mean follow-up period of 126.9 months. The survivorship, radiological and clinical outcomes were investigated. Results Radiologically, 107 hips (90.7%) were categorized to Barrack cementing grade A, and 108 stems (91.5%) were inserted in neutral position. All hips were not loose and were not revised due to aseptic loosening. Survival with revision for any reason as the endpoint was 100% after 10 years. At the last follow-up, the mean subsidence was 0.41 mm, and the subsidence was less than 1 mm in 110 hips (93.2%). JOA hip score improved from 42.7 ± 9.2 points preoperatively to 92.9 ± 6.8 points at the last follow-up. No patient complained thigh pain. Conclusions Line-to-line cementing technique with use of a triple-tapered polished stem was effective to achieve good cementation quality and centralization of the stem. The subsidence was small, and the minimum ten-year results were excellent without any failures related to the stem.Trial registration: Retrospectively registered

Modified hybrid cementing technique reduces stem tip pain and improves patient’s satisfaction after revision total knee arthroplasty

Background There have been no studies comparing patient-reported outcome measures including end-of-stem tip pain and patient satisfaction based on the use of cementing techniques in revision total knee arthroplasty (TKA). The purpose of this study was to compare end-of-stem tip pain and PROMs with hybrid and modified hybrid cementing techniques in revision TKAs. Method Sixty-two cases of revision TKA performed by a single surgeon were divided into two groups based on the cementing technique with a minimum follow-up of 2 years. Two types of cementing technique for femoral and tibial stems were used as follows: (1) a hybrid cementing technique (33 cases), in which cement was applied immediately distal to the modular junction of the stem and the component while the distal stem was press-fitted into the diaphysis without using cement; and (2) a modified hybrid cementing technique (29 cases), in which cement was applied to the tip of femoral and tibial stems. The thigh and shin were assessed for the end-of-stem tip pain. Patient satisfaction was evaluated based on the satisfaction items of New Knee Society Score. Results Modified hybrid cementing significantly lowered the percentage of patients manifesting shin pain (3.4% vs. 24.2%, p = 0.029). Patients treated with the modified hybrid cementing technique showed a higher satisfaction rate (p = 0.003). Multivariate logistic regression analysis showed an increase in the odds of satisfaction 32.686-fold (p = 0.004) in patients without pain at the end-of-stem tip in the shin and 9.261-fold (p = 0.027) in patients treated with the modified hybrid cementing technique. Conclusion The modified hybrid cementing technique for fixation of long-stem in revision TKAs reduced the end-of-stem tip pain in the shin, leading to significantly higher satisfaction compared with the hybrid cementing technique after revision TKA. Level of evidence Level III

Does the line-to-line cementing technique of the femoral stem create an adequate cement mantle?

Background: The line-to-line cementing technique is proposed to create a press-fit in the femoral canal, which is contrary to modern cementing techniques. The term ‘French paradox’ has been used to describe the acceptable results associated with this technique. It has been suggested that the quality of the mantle may not be satisfactory, predisposing to early failure and aseptic loosening. Methods: The line-to-line cementing technique, where the femoral stem was oversized by 1 size compared to the broach, was compared to the standard cementing technique using corresponding sized broaches and stems, in 6 pairs of human cadaver femora with taper-slip design C-stems. Cement pressure was measured, and cement mantle thickness was analysed. A mixed effects model with random intercepts was used to examine the relationship between thickness of mantle and cementing technique and between pressure and cementing technique. Results: Line-to-line cementing results in significantly higher pressurisation for longer periods of time leading to better interdigitation but a thinner mantle in some areas. Conclusions: The results of this study describe the in-vitro advantages and disadvantages of the line-to-line cementing technique.