Hip Arthroplasty Cemented: A Comprehensive Guide to This Successful Procedure

Comprehensive Introduction and Patho-Epidemiology

For more than four decades, cemented total hip arthroplasty (THA) has stood as the gold standard and one of the most successful surgical interventions for end-stage hip disease. Pioneered by Sir John Charnley in the 1960s with the advent of low-friction arthroplasty, the procedure revolutionized the management of debilitating hip pathology. The fundamental principle of utilizing polymethylmethacrylate (PMMA) to act as a grout—rather than an adhesive—between the host bone and the prosthetic implant allows for immediate mechanical stability, uniform load transfer, and the mitigation of stress shielding. Cemented THA remains highly appropriate and often superior for the treatment of hip pathology caused by a vast array of degenerative, inflammatory, traumatic, vascular, developmental, and metabolic disorders, particularly in patients with compromised bone quality.

Degenerative joint disease (DJD), or osteoarthritis, constitutes the final common pathway for various hip disorders of distinct etiologies. The natural history of DJD is characterized by an inexorable progression of articular cartilage degradation, subchondral sclerosis, osteophyte formation, and cyst development. While clinical symptoms may wax and wane, the trajectory is generally one of increasing severity, frequency, and debilitation over time. Developmental abnormalities of the hip frequently precipitate this cascade by inducing femoroacetabular impingement (FAI), abnormal joint reaction forces, and focal articular shear forces. Such anatomic aberrations include developmental dysplasia of the hip (DDH), coxa profunda, protrusio acetabulae, acetabular retroversion, pistol-grip deformity of the proximal femur, Legg-Calvé-Perthes disease, and slipped capital femoral epiphysis (SCFE). In these scenarios, the altered biomechanics accelerate mechanical joint degeneration long before the typical age of onset for primary idiopathic osteoarthritis.

Beyond mechanical and developmental etiologies, a myriad of systemic and traumatic conditions precipitate end-stage hip arthropathy necessitating cemented reconstruction. Rheumatologic conditions, including rheumatoid arthritis and the seronegative spondyloarthropathies, are driven by autoimmune-mediated synovial hypertrophy and subsequent enzymatic destruction of the articular cartilage. Although modern disease-modifying antirheumatic drugs (DMARDs) and biologic agents have dramatically altered the medical management of these conditions, end-stage joint destruction still frequently mandates arthroplasty. Furthermore, osteonecrosis (avascular necrosis) of the femoral head can result from numerous etiologic factors that disrupt the delicate vascular supply to the subchondral bone. These include chronic alcoholism, high-dose corticosteroid use, chemotherapeutic agents, sickle cell disease, systemic lupus erythematosus, vasculitis, human immunodeficiency virus (HIV) infection, and underlying coagulopathies.

Less commonly, metabolic disorders such as hemochromatosis and ochronosis, as well as hematologic abnormalities like hemophilia, can cause advanced, rapid degeneration of the hip joint. Rare congenital disorders, including epiphyseal and spondyloepiphyseal dysplasias, also present unique reconstructive challenges due to profound anatomic distortion and poor bone stock. In the setting of such diverse patho-epidemiology, cemented THA offers a versatile, forgiving, and highly durable solution. Unlike cementless fixation, which relies on the biologic potential of the host bone for osseointegration, cemented fixation is independent of the host's osteogenic capacity, making it particularly invaluable in irradiated bone, severe osteoporosis, and systemic metabolic bone diseases.

Detailed Surgical Anatomy and Biomechanics

The hip is a classic diarthrodial synovial joint, consisting of the articulation between the spherical femoral head and the hemispherical acetabulum of the pelvis. It functions as a highly constrained ball-and-socket joint, with inherent bony architecture that defines its intrinsic stability and physiologic range of motion. The deep concavity of the acetabulum, augmented by the fibrocartilaginous labrum, provides exceptional osseous and soft-tissue coverage of the femoral head. The laxity or tightness of the robust capsular ligaments—specifically the iliofemoral (Y ligament of Bigelow), pubofemoral, and ischiofemoral ligaments—profoundly affects joint kinematics, proprioception, and functional limits. Understanding this anatomy is paramount when performing a cemented THA, as the surgeon must meticulously restore the center of rotation and soft-tissue tension to optimize biomechanics and prevent instability.

Embryologically and structurally, the acetabulum develops at the junction of three distinct hemipelvic bones: the ilium (superiorly), the ischium (posteroinferiorly), and the pubis (anteromedially). These three elements converge and fuse at the triradiate cartilage during early adolescence. The spatial orientation of the acetabulum is critical for both natural hip function and prosthetic positioning. Typically, the native acetabulum demonstrates 15 to 20 degrees of anteversion and approximately 40 to 45 degrees of inclination. The proximal femur, particularly the femoral neck, also naturally exhibits 15 to 20 degrees of anteversion relative to the trans-epicondylar axis of the distal femur. Consequently, the normal combined anteversion (often referred to as the McKibbin index) ranges from 30 to 40 degrees. However, this degree of version varies considerably among individuals, particularly in the setting of developmental dysplasia or neuromuscular disorders, necessitating careful intraoperative assessment to avoid impingement and dislocation.

Biomechanically, the hip joint is subjected to extraordinary forces during routine activities of daily living. Joint reaction forces can exceed three to six times body weight during normal walking and up to ten times body weight during running or jumping. The static and dynamic stability of the pelvis during the single-leg stance phase of gait is entirely dependent on the abductor musculature (gluteus medius and minimus) counterbalancing the body's center of gravity. The ratio of the abductor moment arm to the body weight moment arm dictates the magnitude of the joint reaction force across the articular surface. In cemented THA, precisely restoring the femoral offset (the perpendicular distance from the center of rotation to the anatomic axis of the femur) is essential to optimize the abductor moment arm. Failure to restore offset results in abductor weakness, increased joint reactive forces, accelerated polyethylene wear, and a persistent Trendelenburg gait.

The osseous architecture of the proximal femur is uniquely adapted to transmit these immense loads. The trabecular patterns—specifically the primary compressive and primary tensile trabeculae—intersect to form a highly efficient load-bearing structure. In cemented femoral fixation, the PMMA mantle must interface intimately with the endosteal cancellous bone to distribute shear and compressive forces evenly across the proximal femur. The morphology of the proximal femoral canal, often categorized by the Dorr classification, dictates the ease of achieving a uniform cement mantle. Dorr Type A (champagne flute) and Type B (normal) femurs offer excellent geometry for pressurization, whereas Dorr Type C (stovepipe) femurs, characterized by thin cortices and a wide canal, are mechanically challenging but represent the classic indication for cemented fixation due to the inability to achieve reliable press-fit stability.

Exhaustive Indications and Contraindications

The decision to utilize cemented fixation in total hip arthroplasty requires a nuanced understanding of patient demographics, bone quality, anatomic deformity, and the specific biomechanical demands that will be placed upon the construct. Reproducible, durable, long-term outcomes using cement fixation have historically been achieved in older, lighter patients—particularly women—with low to moderate activity levels and relatively normal macroscopic anatomy of the pelvis and proximal femur. In patients over the age of 70, particularly those with osteopenia or frank osteoporosis (Dorr Type C bone), cemented femoral fixation remains an undisputed gold standard, virtually eliminating the risk of intraoperative periprosthetic fractures that plague uncemented stems in this demographic.

Beyond the standard elderly demographic, cemented fixation is often the best, and sometimes the only, viable option in the face of severely distorted femoral anatomy or compromised host bone biology. When prior trauma, previous osteotomies, or congenital deformities (such as severe coxa vara or proximal femoral focal deficiency) preclude the use of standard diaphyseal-engaging press-fit prostheses, a cemented stem can be custom-positioned within the prepared canal to bypass the deformity. Furthermore, in pathologic bone associated with primary bone tumors, metastatic disease, or prior pelvic/femoral irradiation, the biologic potential for osteointegration is profoundly diminished or entirely absent. In these scenarios, the immediate, rigid mechanical interlock provided by PMMA is essential for early mobilization and functional recovery.

While the indications for cemented THA are broad, specific contraindications must be rigorously respected to prevent catastrophic failure. Absolute contraindications include active local or systemic infection, severe medical comorbidities precluding anesthesia, and active neuroarthropathy (Charcot joint), which invariably leads to rapid mechanical loosening and destruction of the arthroplasty due to absent proprioceptive feedback. Relative contraindications primarily revolve around patient age and activity level. In young, highly active, and heavy patients, the cyclic loading placed upon the cement mantle can lead to early fatigue failure of the PMMA, micro-fragmentation, and subsequent aggressive macrophage-mediated osteolysis. In these demographics, uncemented, biologically integrating implants are generally preferred to ensure longevity.

Summary of Indications and Contraindications

Pre-Operative Planning, Templating, and Patient Positioning

Thorough preoperative planning is the cornerstone of a successful cemented total hip arthroplasty. The initial evaluation must focus on identifying the extent to which the patient's pain and disability can be definitively attributed to intra-articular hip pathology rather than extra-articular or referred sources. Hip pain is classically referred to the groin, but may also present in the peritrochanteric region, the anterior thigh, the knee, or occasionally, below the knee. Lumbar spine disease, specifically spinal stenosis or radiculopathy, frequently masquerades as or coexists with hip osteoarthritis. Although the source of the pain usually can be identified via a meticulous physical examination, occasionally selective image-guided intra-articular anesthetic injections are necessary to elucidate the relative contributions of overlapping pathologies to the patient’s symptom complex.

Physical examination begins with observation of the patient's gait. A Trendelenburg gait suggests profound abductor weakness or severe hip discomfort, whereas a stiff hip gait may be present with hypertrophic osteoarthritis. Leg-length discrepancy must be carefully assessed; while apparent shortening may result from adduction contractures or pelvic tilt secondary to spinal deformity, true osseous shortening is common in advanced DJD and DDH. Specific tests are paramount: the Thomas test identifies fixed flexion contractures, the Ober test reveals iliotibial band tightness (which must not be misinterpreted intraoperatively as overlengthening), and a straight leg raise assesses for concurrent lumbar radiculopathy. Furthermore, evaluating the motor power of the abductors is critical, as preoperative abductor weakness significantly diminishes the likelihood of achieving a limp-free hip postoperatively.

High-quality orthogonal imaging is mandatory. Plain radiographs should include a weight-bearing low anteroposterior (AP) view of the pelvis centered over the pubic symphysis, capturing the proximal third of the femora. Slight internal rotation of the hips (15 degrees) compensates for femoral anteversion, allowing accurate assessment of the true neck-shaft angle and offset. An AP and false-profile view of the involved hip provide critical information regarding anterior and lateral acetabular coverage. The false-profile view of Lequesne is particularly reliable for templating acetabular size and evaluating the anterior column. Supplemental studies such as CT or MRI are rarely needed for primary osteoarthritis but are invaluable for assessing bone stock in severe protrusio, post-traumatic deformity, or suspected avascular necrosis.

Templating is an exacting science that dictates implant selection and intraoperative execution. Once the implant system is chosen, digital or acetate templates are used to predict implant size, restore the center of rotation, optimize offset, and equalize leg lengths. A horizontal reference line is drawn between the inferior tips of the acetabular teardrops. The perpendicular distance from this inter-teardrop line to the medial tip of the lesser trochanter is measured to calculate the preoperative leg-length discrepancy (LLD). The center of the native femoral head is marked, and the lesser trochanter-to-center distance (LTC) is recorded. During templating, the surgeon seeks to position the acetabular component at the anatomic center of rotation, while selecting a femoral neck cut and stem size that restores the LTC and lateral offset, typically aiming for a slight increase in leg length (2 to 5 mm) to ensure soft-tissue tension and joint stability.

Step-by-Step Surgical Approach and Fixation Technique

The surgical approach to the hip—whether posterior, anterolateral, or direct anterior—dictates the sequence of exposure but does not alter the fundamental principles of cemented fixation. Regardless of the chosen interval, meticulous hemostasis and circumferential exposure of the acetabulum and proximal femur are required. Once the hip is dislocated and the femoral neck is resected according to the preoperative template, attention is turned to the acetabulum. The labrum is excised, and the acetabulum is sequentially reamed to expose bleeding subchondral bone. Unlike cementless cups that rely on an interference fit, the cemented acetabulum requires the preservation of strong subchondral bone to support the cement mantle. Multiple 6-mm to 8-mm anchor holes are often drilled into the ilium, ischium, and pubis to enhance the macroscopic interdigitation of the PMMA.

Preparation of the femoral canal is arguably the most critical step in determining the longevity of a cemented stem. The canal is broached and reamed to remove all loose cancellous bone, leaving a 2-mm to 3-mm bed of strong, trabecular bone to interlock with the cement. Third-generation cementing techniques are mandatory. This involves aggressive pulsatile lavage to remove marrow fat, blood, and debris, followed by the insertion of an intramedullary distal cement restrictor (plug) to allow for subsequent pressurization. The canal is then dried meticulously, often utilizing epinephrine-soaked sponges or hydrogen peroxide, as a dry interface is essential for optimal cement penetration into the cancellous interstices.

The rheology and handling of the PMMA are highly sensitive to temperature and technique. The cement must be vacuum-mixed to eliminate air voids, which act as stress risers and weaken the mantle. Once the cement reaches the early dough phase, it is injected into the femoral canal in a retrograde fashion using a cement gun with a long nozzle, starting at the restrictor and slowly withdrawing to prevent the entrapment of blood or air. A proximal seal is applied, and the cement is aggressively pressurized to drive it into the trabecular bone, creating a micro-interlock. The selected femoral component is then inserted in the correct version, maintaining continuous axial pressure until the cement has fully polymerized.

Implant selection heavily influences the fixation philosophy. There are two primary design rationales for cemented femoral stems: the "shape-closed" (composite beam) design and the "force-closed" (taper slip) design. Shape-closed stems, such as the Charnley prosthesis, feature a matte or roughened surface intended to bond rigidly with the cement, preventing any micro-motion. Conversely, force-closed stems, like the Exeter polished taper, are highly polished and collarless; they are designed to act as a wedge, subsiding slightly into the cement mantle under axial load to maintain compressive forces at the cement-bone interface. Both philosophies have demonstrated excellent long-term survivorship, but "mixing and matching" design elements (e.g., roughening a taper-slip stem) leads to catastrophic early aseptic loosening.

Complications, Incidence Rates, and Salvage Management

While cemented THA is a highly successful operation with outstanding short- and intermediate-term outcomes, it is not immune to complications. Significant early complications are uncommon, but long-term outcomes beyond 15 to 20 years are frequently limited by component wear, fatigue failure of the cement mantle, and the host's biologic reaction to particulate wear debris. Aseptic loosening remains the most common mode of failure in the long term. On the femoral side, improvements in third-generation cementing techniques have dramatically reduced aseptic loosening rates to less than 5% at 15 years. However, acetabular cement fixation remains challenging; the appearance of the bone-cement interface on the immediate postoperative radiograph—specifically the presence of radiolucent lines in the DeLee and Charnley zones—strongly predicts the durability of the acetabular component.

A unique and potentially life-threatening intraoperative complication specific to cemented arthroplasty is Bone Cement Implantation Syndrome (BCIS). BCIS is characterized by sudden hypoxia, hypotension, cardiac arrhythmias, increased pulmonary vascular resistance, and potentially cardiac arrest occurring at the time of cement pressurization or prosthesis insertion. The pathophysiology is multifactorial, primarily driven by the embolization of marrow fat, bone fragments, and PMMA monomer into the venous circulation due to the high intramedullary pressures generated during cementing. Management requires immediate communication with the anesthesia team, aggressive fluid resuscitation, administration of 100% oxygen, and vasopressor support. Preventative measures include meticulous canal lavage, venting of the femur, and careful patient selection.

Other complications include periprosthetic joint infection (PJI), instability (dislocation), periprosthetic fractures, and venous thromboembolism (VTE). PJI is a devastating complication occurring in 1-2% of primary cases. In cemented THA, the use of antibiotic-loaded bone cement (ALBC) provides high local concentrations of antibiotics (typically tobramycin, gentamicin, or vancomycin) without systemic toxicity, significantly reducing the incidence of infection. Salvage management of a failed cemented THA, whether from infection or aseptic loosening, requires complex revision surgery. Removing a well-fixed cement mantle can be extremely difficult and carries a high risk of iatrogenic bone loss, cortical perforation, or fracture, often necessitating the use of specialized ultrasonic cement removal tools, flexible osteotomes, or an extended trochanteric osteotomy (ETO).

Common Complications and Management Strategies

Phased Post-Operative Rehabilitation Protocols

The immediate mechanical stability afforded by a polymerized PMMA mantle allows for

Clinical & Radiographic Imaging Archive