High-yield overview
Modern cemented femoral fixation using third and fourth-generation cementing principles for elderly patients, osteoporotic bone, and acute femoral neck fractures
arthroplastySubspecialty
14Operative steps
CRISPThe five principles
105 minTypical duration
Critical Must-Knows
- Third-generation cementing is CRISP: a distal Cement restrictor, Retrograde cement insertion, pulsatile Irrigation (lavage), Stem centralization, and Pressurization. Without the distal restrictor the canal is an open system and pressurization is impossible, so modern cementing cannot be performed at all.
- Fourth-generation cementing adds vacuum mixing of the cement (cuts porosity by 80 to 90 percent and lifts fatigue strength by 30 to 50 percent) and modern polished-taper stem designs with improved centralizers.
- Modern cemented polished-taper stems achieve about 95 percent survival at 15 years (AOANJRR) and around 90 percent at 25 years (Swedish Registry) - among the best-performing femoral components.
- Cementing is indicated for age over 70 to 75 years, osteoporotic bone (Dorr C, Singh index less than 3) and acute femoral neck fractures. In patients over 75, cemented fixation has a LOWER revision rate than uncemented (hazard ratio 0.85).
- Pressurization drives cement 2 to 3mm into trabecular bone for mechanical interdigitation - the fundamental mechanism of cement fixation - versus less than 1mm without pressure.
- Broach to SIZE leaving 2 to 3mm of space for the mantle - the opposite of uncemented press-fit. A mantle thinner than 2mm carries roughly four-fold higher stress and fails early.
When & Why
Modern cemented femoral fixation using third and fourth-generation cementing principles is the gold standard for total hip replacement in older and osteoporotic patients, and for acute femoral neck fractures. It is the same operation whatever surgical approach is used - what defines it is meticulous canal preparation, retrograde cement delivery, and pressurization that locks the stem into the trabecular bone. Done well, it is one of the most durable constructs in orthopaedics; done poorly (first-generation finger-packing), it failed in 30 to 40 percent at ten years. ### Indications The technique is chosen for patients whose bone cannot reliably hold an uncemented press-fit stem, or who need immediate full weight-bearing. - Age over 70 to 75 years - lower activity demand and life expectancy under 20 years; registry data show excellent survival in this group.
- Osteoporotic bone - Dorr C femoral morphology (thin cortices, wide canal) and Singh index less than 3, where cortical bone is too poor for press-fit fixation.
- Acute femoral neck fracture in the elderly (over 65 years) requiring arthroplasty - cemented fixation allows immediate full weight-bearing and carries a four-fold lower periprosthetic fracture rate than uncemented (WHiTE 5).
- Medical bone compromise - rheumatoid arthritis and inflammatory arthropathies, chronic renal disease with metabolic bone disease, Paget disease in a quiescent phase.
- Salvage - conversion of a failed hemiarthroplasty where proximal bone stock remains adequate, and selected revision cases.
Composite-beam stems
Force-closed fixation: a matt surface (e.g. Charnley, Stanmore) is meant to bond to the cement, so the stem-cement composite transfers load together. The cement mantle is load-bearing.
Taper-slip stems
Shape-closed fixation: a polished taper (e.g. Exeter, CPT, C-Stem) subsides a fraction within the cement and loads the cement-bone interface in compression - the modern gold standard, and the best registry performers.
The cement
PMMA bone cement (Palacos, Simplex, CMW), antibiotic-loaded by regional preference, vacuum-mixed to drive porosity down 80 to 90 percent. A typical femur takes 80 to 120g.
Contraindications Absolute - an active infection, a known allergy to cement components (extremely rare), and a young, highly active patient (under 50 to 55 years) where uncemented fixation is preferred. Relative - very young age (under 40 years), high-activity patients, Dorr A bone (dense, narrow canal - better uncemented), and the need for future MRI surveillance (cement artifact is less than the metal artifact of an uncemented stem but still present). ### Preoperative assessment and planning Template on an AP pelvis and lateral hip radiograph for stem size, position, offset and leg length; assess canal dimensions and morphology and flag any deformity or retained hardware. CT is reserved for severe deformity, fracture malunion, or revision cases with bone loss. Stratify the patient for bone cement implantation syndrome (BCIS): the highest-risk groups are age over 80, ASA 3 to 4, significant cardiopulmonary disease, and intertrochanteric or pathological fractures.
Plan for BCIS before you scrub
Discuss the cementing step with the anaesthetist at the WHO briefing. Fluid-load the high-risk patient with 500 to 1000mL of crystalloid beforehand, place an arterial line in the elderly or cardiac patient, and agree the vasopressor plan. The single most important safety step in cemented femoral surgery is this pre-cement time-out.
The Operation
The goal is to seat a polished-taper femoral stem in a continuous, well-pressurized 2 to 3mm cement mantle that interdigitates with clean, dry trabecular bone. The cementing technique is identical regardless of surgical approach - the only requirement is adequate exposure of the femoral canal. The exposure and canal preparation are laid out as the opening steps below (see also the posterior (Moore/Southern) approach to the hip).
Operative sequence
Step 1Position, approach and draping
- Lateral decubitus for posterior or anterolateral approaches, or supine for the direct anterior; ensure the pelvis is stable and perpendicular and all bony prominences are padded.
- The cementing technique does not change with the approach - you simply need enough room to deliver the femur and pass the cement gun.
Step 2Prepare and insert the acetabular component
- Complete acetabular reaming and insert the acetabular component (cemented or uncemented per plan) and confirm it is stable.
- Only then turn to the femur - this keeps the canal work last so the prepared bone is not left open and bleeding.
Step 3Femoral neck osteotomy and canal exposure
- Osteotomize the neck about 1cm proximal to the lesser trochanter in neutral to slight valgus, protecting soft tissues, and remove the head.
- Deliver the proximal femur into the wound - external rotation and adduction for a posterior approach, flexion/adduction/internal rotation for anterolateral, extension and external rotation for anterior.
- Aim for a clear, unobstructed view straight down the canal entry.
Step 4Canal entry and box chisel
- Locate the piriformis fossa (standard entry), or a slightly lateral entry for a valgus stem position.
- Insert the box chisel and direct the handle LATERALLY (valgus) to remove cancellous bone from the proximal metaphysis and open the canal - directing it medially drives the stem into varus and risks the calcar.
Step 5Sequential broaching - to SIZE, not press-fit
- This is the key difference from uncemented surgery: broach to leave a 2 to 3mm circumferential space for cement, NOT to tight cortical contact.
- Start with the smallest broach that engages, advance in neutral to slight valgus at 10 to 15 degrees anteversion, and upsize sequentially to a broach with reasonable (not loose, not tight) stability at the templated depth.
- Over-broaching leaves a thin mantle; under-broaching undersizes the stem; varus broaching and excessive depth risk cortical perforation.
Step 6Trial reduction and implant selection
- Insert a trial stem (often one size smaller than final, since cement adds 2 to 3mm) and trial head, then reduce the hip.
- Check anterior stability (extension and external rotation), posterior stability (flexion, internal rotation, adduction), range of motion for impingement, and the shuck test.
- Set leg length and offset against preoperative marks using head size (usually 28 or 32mm) and neck length (plus 0, plus 3.5, plus 7mm). Record the final selections.
Step 7Cement restrictor insertion - the foundation
- Insert a flexible polyethylene restrictor sized to fit snugly 1 to 2cm distal to the planned stem tip; too proximal and the stem bottoms out, too distal and cement is wasted.
- Confirm it will not advance with gentle pressure - it must occlude the canal to create the closed system that makes pressurization possible.
Step 8Brush, pulsatile lavage and dry (DRY BONE)
- Brush the endosteal surface for 30 to 60 seconds to strip loose cancellous bone, fat and clot.
- Pulsatile lavage with at least 1 litre of normal saline (a bulb syringe is not acceptable) until the effluent is clear - this removes the blood and marrow that block cement penetration and increases penetration 3 to 4 fold.
- Control any bleeding bone with bone wax, then suction the depths and pack with dry gauze; cement will not penetrate wet bone.
Step 9Mix the cement (vacuum, fourth-generation)
- Vacuum-mix if available (reduces porosity 80 to 90 percent, improves fatigue strength 30 to 50 percent); otherwise mix in a bowl per the manufacturer instructions. Typical dose 80 to 120g.
- Watch the phases: liquid (0 to 3 minutes, too runny), DOUGH (3 to 7 minutes, ideal for insertion), and hardening (after 7 to 8 minutes, too late).
Step 10Retrograde cement insertion
- Load the gun in the dough phase, attach a long flexible nozzle, and inject continuously from the restrictor proximally while slowly withdrawing.
- Maintain an unbroken cement column with no pauses - pauses create laminations and air voids, exactly the weak interfaces that defeated old antegrade finger-packing.
Step 11Pressurization
- Seat a pressurizer plug in the proximal canal and hold firm, steady pressure for 30 to 60 seconds until the cement begins to lose its dough consistency.
- This drives the cement 2 to 3mm into trabecular bone for mechanical interdigitation - the basis of fixation. It is only possible because the restrictor has closed the canal.
Step 12Stem insertion and centralization
- At the late dough phase (does not stick to gloves, holds shape but still flows), insert the stem to the predetermined depth and version in ONE smooth motion - never withdraw and reinsert, which creates laminations.
- Use proximal and distal centralizers (especially for Exeter-type tapers) to guarantee a 2 to 3mm circumferential mantle, then hold the position absolutely still until the cement hardens (8 to 12 minutes from mixing).
Step 13Remove excess cement and let it harden
- While holding the stem still, peel away excess cement from the medial calcar, the stem shoulder, the greater trochanter and posteriorly - medial calcar cement prevents reduction, posterior cement threatens the sciatic nerve.
- Wipe the taper completely clean. Hold the stem immovable until the cement is rock hard.
Step 14Final trial reduction, stability and closure
- Inspect the mantle (2 to 3mm, circumferential, no stem-bone contact), clean the taper, seat the definitive head and reduce the hip - difficulty reducing usually means retained medial calcar cement.
- Repeat the stability tests, then irrigate copiously (3 to 6 litres), repair the approach-specific soft tissues (posterior capsule and short rotators for a posterior approach), and close in layers.
Mnemonic
CRISPthe five principles of third-generation cementing
C
Cement restrictor
A distal plug 1 to 2cm beyond the stem tip. Without it the canal is open, pressurization is impossible, and modern cementing cannot be performed.
R
Retrograde insertion
Cement gun injected distal-to-proximal. Prevents the laminations and air voids of old antegrade finger-packing.
I
Irrigation (pulsatile lavage)
At least 1 litre of saline. Removes blood, fat and marrow and increases cement penetration 3 to 4 fold.
S
Stem centralization
Centralizers maintain a 2 to 3mm circumferential mantle. A mantle under 2mm carries roughly four-fold higher stress and fails early.
P
Pressurization
Firm steady pressure drives cement 2 to 3mm into trabecular bone for mechanical interdigitation (under 1mm unpressurized).
Mnemonic
DRY BONEcanal preparation before cementing
D
Debride canal
Curettes and brushes remove loose cancellous bone; broach to SIZE not press-fit, leaving 2 to 3mm for cement.
R
Restrictor placement
Cement restrictor 1 to 2cm distal to the planned stem tip, snug against the canal walls.
Y
Yield to pulsatile lavage
At least 1 litre of normal saline until the effluent runs clear.
B
Brush endosteal surface
Canal brush for 30 to 60 seconds strips adherent debris and clot.
O
Obtain hemostasis
Bone wax or cautery for any bleeding surface - blood blocks cement penetration.
N
Neutralize moisture
Suction the depths and pack dry gauze; the canal must be completely dry.
E
Ensure readiness
Inspect: dry, clean, ready for immediate cement in the dough phase.
Bone cement implantation syndrome - the anaesthetic emergency
BCIS is embolization of cement monomer, fat, marrow, air and bone debris to the pulmonary circulation during cementation or stem impaction, causing pulmonary hypertension, right-heart strain, hypotension and hypoxia. Incidence is 0.5 to 1 percent overall, rising to 2 to 3 percent over age 80 and 5 to 7 percent with intertrochanteric fractures. Prevent it with pre-cement communication with the anaesthetist, fluid loading, thorough lavage and gentle (not forceful) pressurization. If it occurs, stop, call it out, give 100 percent oxygen, fluid-bolus and vasopressors, and escalate to ACLS for grade 3 to 4 collapse.
No restrictor, no pressurization
The cement restrictor is not a convenience - it is the foundation. It converts the open femoral canal into a closed chamber so that the pressurizer can actually drive cement into bone. If it is omitted, misplaced, or loose, cement migrates distally and pressurization is impossible, which is precisely the failure mode of first-generation cementing.
Timing is everything
Cement delivered too early (liquid phase) extrudes and the stem migrates; too late (hardening) the stem will not seat and the mantle fractures. The ideal window is the late dough phase - the cement no longer sticks to the glove but still flows under pressure - and the stem goes in one smooth motion to depth and version and is then held absolutely still.
Why retrograde, not antegrade
Retrograde delivery from the restrictor proximally pushes air and fluid ahead of the advancing column and produces a homogeneous mantle. Antegrade finger-packing traps air between layers, creating multiple weak laminated interfaces - the radiographic voids and the mechanical reason first-generation stems loosened in 30 to 40 percent.
Aftercare & Complications
Immediate post-operative period Standard post-anaesthesia monitoring with multimodal analgesia (paracetamol, NSAIDs, opioids as needed), nausea control, and a haemoglobin check (transfuse under 80 g/L or if symptomatic). An immediate AP pelvis and lateral hip radiograph audits four things: a complete 2 to 3mm cement mantle in all Gruen zones with no voids or stem-bone contact, neutral to slight valgus stem position at the correct depth, no calcar/greater-trochanter/shaft fracture, and the acetabular component within the safe zone. Immediate full weight-bearing is permitted - a major advantage of cemented fixation, in contrast to the 6 to 12 weeks of protected weight-bearing some uncemented stems require. ### Mobilization and hip precautions Mobilize on day 1 (sit out, stand, begin ambulation with a frame or crutches) and practise stairs before discharge. Precautions are approach-dependent for six weeks:
Posterior (Moore/Southern)
- Avoid
- Flexion over 90 degrees, adduction past midline, internal rotation
- Rationale
- Protect the posterior capsular and short-rotator repair (cuts dislocation from about 5 percent to 1 percent)
Anterolateral / lateral
- Avoid
- Extreme external rotation, extension combined with external rotation
- Rationale
- Protect the abductor (gluteus medius) repair
Direct anterior
- Avoid
- No formal precautions required
- Rationale
- Lower dislocation risk - an advantage of the approach
1
- Severity
- Moderate
- Features
- Moderate hypotension or desaturation recovering with fluids and oxygen
- Approximate frequency
- Most common (about 28 percent of events)
2
- Severity
- Severe
- Features
- Severe hypotension or desaturation needing vasopressor support
- Approximate frequency
- About 7 percent
3
- Severity
- Collapse
- Features
- Cardiovascular collapse requiring CPR
- Approximate frequency
- About 0.7 percent
4
- Severity
- Death
- Features
- Fatal cardiovascular collapse
- Approximate frequency
- Rare (about 0.02 percent)
Bone cement implantation syndrome
- Recognition
- Hypotension (systolic drop over 20 percent), desaturation under 94 percent, arrhythmia or arrest within 30 to 60 seconds of cementing
- Prevention
- Communicate with anaesthesia, fluid-load, thorough lavage, gentle pressurization, arterial line in high-risk patients
- Management
- Grade 1: fluids and oxygen. Grade 2: vasopressor infusion. Grade 3 to 4: ACLS, CPR, escalate to ICU
Intraoperative periprosthetic fracture
- Recognition
- Sudden loss of calcar support, a palpable step-off at the greater trochanter, or abnormal shaft mobility
- Prevention
- Gentle sequential broaching, box chisel directed laterally, image intensifier for difficult anatomy
- Management
- Non-displaced calcar: proceed, cement holds it. Displaced calcar: cerclage. Trochanter: tension band. Shaft: extend approach, ORIF with plate/cables, consider a long stem
Inadequate cement mantle (under 2mm)
- Recognition
- Post-op radiograph: mantle under 2mm, voids, or stem-bone contact (Gruen zones)
- Prevention
- Broach to size not press-fit, use centralizers, adequate cement volume 80 to 120g, avoid oversized stems
- Management
- Intraoperative: remove and re-cement while soft. Post-op asymptomatic: observe with serial films. Symptomatic or progressive: revise
Cement extravasation and nerve injury
- Recognition
- Sciatic: foot drop and posterior-leg sensory loss. Femoral: quadriceps weakness. May be immediate or delayed 24 to 48 hours
- Prevention
- Know the nerve anatomy, careful retractor placement, remove posterior cement before closure, palpate for extruded cement
- Management
- Urgent CT; if cement compresses the nerve, explore and remove within 24 to 48 hours for best prognosis; otherwise physiotherapy
Aseptic loosening
- Recognition
- Progressive weight-bearing thigh pain, radiolucent lines over 2mm at the cement-bone interface, subsidence over 5mm, cement fracture
- Prevention
- Meticulous CRISP technique, 2 to 3mm penetration and mantle, reserve for low-demand elderly
- Management
- Asymptomatic and stable: observe. Symptomatic or progressive: revision (uncemented if good stock, re-cement if elderly with good proximal bone, impaction grafting or tapered fluted modular stems for deficient bone)
Infection (early or late)
- Recognition
- Early (under 3 months): drainage, erythema, raised CRP/ESR. Late: insidious pain, persistent CRP over 10. Aspiration culture 85 to 90 percent sensitive
- Prevention
- Screen and decolonize S. aureus, antibiotic prophylaxis (cefazolin 2g or vancomycin 15mg/kg), laminar flow, meticulous closure
- Management
- Acute (under 3 weeks): DAIR if implant stable. Chronic: two-stage revision (stage 1 spacer and organism-specific IV antibiotics, stage 2 reimplant after markers normalize). Selected cases: one-stage
Dislocation
- Recognition
- Acute pain, shortening and deformity; posterior (90 percent) the leg is adducted and internally rotated; anterior it is abducted and externally rotated
- Prevention
- Lewinnek safe zone (inclination 40 plus or minus 10 degrees, anteversion 15 plus or minus 10 degrees), restore offset, larger head, repair posterior capsule and rotators
- Management
- First event: closed reduction, precautions, abductor strengthening. Recurrent: revise for cause (malposition, impingement, abductor insufficiency)
Leg-length discrepancy
- Recognition
- Patient reports one leg longer or shorter; measure ASIS to medial malleolus; over 10mm usually symptomatic
- Prevention
- Preoperative templating, intraoperative reference marks, trial with multiple head lengths, confirm equal knee heights
- Management
- Under 10mm and asymptomatic: reassure. 10 to 20mm: shoe lift and gait training. Over 20mm or poorly tolerated: consider early revision
Viva & Exam Focus
Critical danger structures
Femoral cortex
Anterior and lateral cortex during broaching. Perforation loses pressurization and produces a thin or absent mantle. Prevent it with gentle broaching, feeling for cortical contact, and image intensifier when the canal is unclear.
Calcar femorale
The posteromedial proximal femur. A calcar fracture compromises the proximal mantle and stem stability. Direct the box chisel laterally, avoid aggressive medial impaction, and broach in a controlled fashion.
Greater trochanter
The abductor attachment. Trochanteric fracture or avulsion causes abductor dysfunction and a Trendelenburg gait. Elevate soft tissue carefully, avoid excessive retraction, and insert the stem gently.
Sciatic nerve
Posterior to the acetabulum, 1 to 2cm behind the joint in the posterior approach. At risk from retractors and from posterior cement extrusion or haematoma. Mark it, place retractors carefully, and remove posterior cement before closing.
Cardiovascular system (BCIS)
Systemic. Fat, marrow and cement emboli to the lungs cause hypotension, arrhythmia and arrest (0.5 to 1 percent incidence). Communicate with anesthesia, lavage thoroughly, pressurize gently, and fluid-load.
Cement mantle itself
Not a nerve, but the structure that fails. A mantle under 2mm carries roughly four-fold higher stress. Audit it on the lateral film in every Gruen zone and use centralizers to protect zones 8, 9 and 12.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
Viva scenarioModerate
Clinical prompt
“Describe the key principles of third-generation cementing technique and explain why each is important.”
Viva scenarioCritical
Clinical prompt
“You are cementing a femoral stem in an 82-year-old with an acute femoral neck fracture. As you insert the cement, the anaesthetist reports the blood pressure has dropped from 120/70 to 75/40 and the oxygen saturation from 98 percent to 89 percent. What is happening and what do you do?”
Viva scenarioAdvanced
Clinical prompt
“On the post-operative radiograph after your cemented THR, the cement mantle is only 1mm thick in Gruen zones 2 and 6, with stem-bone contact visible in zone 3. What are the implications and what would you do?”
Exam day cheat sheet
Cemented femoral technique - exam-day summary
When to cement
- Age over 70 to 75 years (95 percent survival at 15 years); osteoporotic Dorr C, Singh under 3
- Acute femoral neck fracture - immediate full weight-bearing and four-fold lower periprosthetic fracture (WHiTE 5)
- Rheumatoid or inflammatory arthropathy with poor bone for press-fit; selected revision with good proximal stock
- Over 75 years cemented beats uncemented (lower revision, HR 0.85)
Third-generation (CRISP)
- C - Cement restrictor 1 to 2cm beyond the stem tip (essential, or pressurization is impossible)
- R - Retrograde insertion from distal to proximal (no laminations or voids)
- I - Irrigation: pulsatile lavage at least 1 litre (penetration up 3 to 4 fold)
- S - Stem centralization (2 to 3mm mantle; under 2mm is four-fold higher stress)
- P - Pressurization 30 to 60 seconds (cement in 2 to 3mm vs under 1mm)
- Fourth-generation adds vacuum mixing (porosity down 80 to 90 percent, fatigue up 30 to 50 percent)
Canal prep (DRY BONE)
- Debride; broach to SIZE not press-fit, leaving 2 to 3mm
- Restrictor 1 to 2cm beyond the stem tip, snug fit
- Yield to pulsatile lavage until effluent clear
- Brush 30 to 60 seconds; obtain hemostasis; dry completely
Cement timing and insertion
- Phases: liquid 0 to 3 min, DOUGH 3 to 7 min (ideal), hardening after 7 to 8 min
- Retrograde gun injection: continuous, no pauses (no laminations)
- Pressurize in the dough phase, then stem in ONE motion to depth and version
- Hold still 8 to 12 minutes - never withdraw and reinsert
Danger structures
- Femoral cortex perforation - gentle broaching, image intensifier
- Calcar fracture - box chisel lateral, not medial
- Greater trochanter - careful elevation, gentle insertion
- Sciatic nerve - mark it, careful retractors, remove posterior cement
- BCIS - communicate, fluid-load, lavage, arterial line in high-risk
Post-op and follow-up
- Immediate X-ray: 2 to 3mm mantle all Gruen zones, neutral-to-valgus stem, no fracture, cup in safe zone
- Immediate FULL weight-bearing (advantage over uncemented)
- Precautions: 6 weeks if posterior (no flexion over 90, adduction, IR); minimal if lateral; none if anterior
- Follow-up: 6wk X-ray, 3mo clinical, 1yr baseline X-ray, then 2 to 5 yearly
- Watch for radiolucencies over 2mm, subsidence over 5mm, cement fracture
Complications
- BCIS: SBP drop over 20 percent or SpO2 under 94 percent during cementing, Donaldson grade 1 to 4
- Intraop fracture: calcar (proceed/cerclage), trochanter (tension band), shaft (ORIF, long stem)
- Thin mantle: under 2mm or stem-bone contact, four-fold higher stress, 15 to 20 percent failure at 10yr
- Aseptic loosening: progressive thigh pain, radiolucencies over 2mm, subsidence over 5mm
Registry data
- AOANJRR cemented: 94.6 percent at 15yr, 91.2 percent at 20yr (Exeter best 95.8 percent)
- Over 75: cemented better than uncemented (HR 0.85)
- Swedish: Exeter about 90 percent, Charnley about 88 percent at 25 years
- Technique impact: 3rd-gen 5 percent revision at 15yr vs 1st-gen 30 to 40 percent
Background & Evidence
Historical evolution of cementing The survival of cemented stems is overwhelmingly a function of technique. The four generations map directly onto falling failure rates:
First
- Era
- 1960s to 1970s
- Defining features
- Antegrade finger-packing; no lavage, no restrictor, no pressurization, no centralization
- Result
- 30 to 40 percent failure at 10 years
Second
- Era
- 1980s
- Defining features
- Cement gun for insertion; still antegrade; basic lavage; limited pressurization
- Result
- 15 to 20 percent failure at 10 years
Third
- Era
- 1990s to 2000s
- Defining features
- Distal restrictor, pulsatile lavage, retrograde insertion, systematic pressurization, centralization
- Result
- 5 to 10 percent failure at 15 years
Fourth
- Era
- 2000s to present
- Defining features
- All third-generation plus vacuum mixing, polished-taper stems and improved centralizers
- Result
- About 95 percent survival at 15 years, about 90 percent at 25 years
A
- Cortical pattern
- Thick cortices, dense metaphyseal bone
- Canal
- Narrow
- Best fixation
- Uncemented (press-fit holds well)
B
- Cortical pattern
- Intermediate cortical thickness and density
- Canal
- Intermediate
- Best fixation
- Either cemented or uncemented
C
- Cortical pattern
- Thin cortices, osteoporotic, wide canal
- Canal
- Wide
- Best fixation
- Cemented (the ideal indication)
6 to 5
- Trabecular pattern
- Normal trabeculae
- Bone quality
- Normal
- Cemented?
- Uncemented reasonable
4 to 3
- Trabecular pattern
- Reduced trabeculae
- Bone quality
- Reduced
- Cemented?
- Consider cemented
2 to 1
- Trabecular pattern
- Severe osteoporosis
- Bone quality
- Poor
- Cemented?
- Cemented indicated
AOANJRR (cemented, all ages)
- Survival
- 94.6 percent at 15 years; 91.2 percent at 20 years
- Note
- Exeter best performer (95.8 percent at 15 years)
AOANJRR (over 75 years)
- Survival
- 96 to 97 percent at 15 years
- Note
- Lower revision than uncemented (HR 0.85, 95 percent CI 0.79 to 0.91)
Swedish (SHAR)
- Survival
- Exeter about 90 percent; Charnley about 88 percent at 25 years
- Note
- Benchmark durability of the cemented construct
UK NJR
- Survival
- Exeter V40 97.2 percent; CPT 96.8 percent; C-Stem AMT 96.1 percent at 15 years
- Note
- Grade A registry evidence
Technique impact
- Survival
- Third-generation about 5 percent revision at 15 years vs first-generation 30 to 40 percent
- Note
- Technique is the dominant variable
References
Evidence
Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty: a 12-year radiographic review
Barrack RL, Mulroy RD Jr, Harris WH • Journal of Bone and Joint Surgery (British) (1992)
Key Findings:
- 50 modern (second/third-generation) cemented arthroplasties in 44 patients aged 50 years or younger, reviewed at a mean of 12 years (10 to 14.8) with no loss to follow-up
- Cement delivered by gun into a canal occluded distally with a cement plug (restrictor) - the defining advance over hand-packing
- NO femoral component was revised for aseptic loosening; only one stem was definitely radiographically loose
- By contrast the cemented acetabular component performed poorly (11 revised, 11 more radiographically loose), localising the failure problem to the socket not the modern-cemented stem
Clinical implication: The landmark study showing that gun-delivered, distally-plugged (modern) femoral cementing produces durable fixation even in young high-demand patients, where first-generation hand-packing failed in 30 to 40 percent. Establishes the femoral stem-cement-bone construct as the durable element when technique is meticulous.
Evidence
Dependency of cement mantle thickness on femoral stem design and centralizer
Breusch SJ, Lukoschek M, Kreutzer J, Brocai D, Gruen TA • Journal of Arthroplasty (2001)
Key Findings:
- Cadaver study of 48 femora with 4 stem designs analysed radiographically and microradiographically for cement mantle defects in all Gruen zones
- Thin mantles (under 2mm) clustered in the sagittal plane - Gruen zones 8 and 9 (proximal, 39 defects) and zone 12 (distal, 21 defects)
- Straight stems without a centralizer had a 93 percent risk of a thin distal mantle in zone 12; centralizers abolished distal thin mantles but did NOT help proximally
- Anatomic stem design carried the lowest proximal risk (54 percent) and lateral radiographs were essential to detect sagittal-plane mantle deficiency
Clinical implication: Demonstrates exactly where deficient cement mantles arise and that a distal centralizer prevents distal (zone 12) thin mantles but not proximal anteversion/flexion-related defects. Justifies routine use of stem centralizers and mandatory lateral post-operative radiographs to audit mantle quality.
Evidence
Cemented or Uncemented Hemiarthroplasty for Intracapsular Hip Fracture (WHiTE 5)
Fernandez MA, Achten J, Parsons N, Griffin XL, Png ME, Costa ML, et al. • New England Journal of Medicine (2022)
Key Findings:
- Multicentre RCT of 1225 patients aged 60 or older with intracapsular hip fracture: 610 cemented versus 615 modern uncemented hemiarthroplasty
- Cemented fixation gave a modestly better health-related quality of life at 4 months (EQ-5D 0.371 versus 0.315; adjusted difference 0.055, 95 percent CI 0.009 to 0.101; P=0.02)
- Periprosthetic fracture occurred in 0.5 percent of cemented versus 2.1 percent of uncemented hips (odds ratio for uncemented 4.37, 95 percent CI 1.19 to 24.00)
- 12-month mortality did not differ significantly (23.9 percent cemented versus 27.8 percent uncemented; OR 0.80, 95 percent CI 0.62 to 1.05)
Clinical implication: High-quality randomised evidence that, in the elderly fracture population, cemented fixation reduces periprosthetic fracture roughly four-fold and improves early quality of life without increasing mortality - directly supporting cementing as the default for osteoporotic and fracture femora.
Evidence
Bone cement implantation syndrome (BCIS): definition, grading, and prevention
Donaldson AJ, Thomson HE, Harper NJ, Kenny NW • British Journal of Anaesthesia (2009)
Key Findings:
- Defines BCIS as intraoperative hypotension, hypoxia, arrhythmia or cardiac arrest temporally related to cementation or prosthesis insertion, and proposes the now-standard severity grading (grade 1 to 3)
- Aetiology is embolic - cement monomer, fat, marrow, air and bone debris pressurised into the venous circulation causing pulmonary hypertension and right-heart strain
- Identifies high-risk groups: advanced age, ASA 3 to 4, significant cardiopulmonary disease, pre-existing pulmonary hypertension and intertrochanteric/pathological fractures
- Recommends pre-cement haemodynamic optimisation, surgeon-anaesthetist communication, lavage and gentle pressurisation, and considering uncemented fixation or invasive monitoring in the highest-risk patients
Clinical implication: The reference framework for recognising, grading and managing BCIS. Drives the mandatory pre-cementing time-out with anaesthesia, fluid optimisation, thorough lavage and patient selection in the frail elderly - the single most important safety step in cemented femoral surgery.
Evidence
National joint replacement registries: long-term survivorship of cemented femoral stems
NJR (UK), AOANJRR (Australia), Swedish Arthroplasty Register (SHAR), AJRR (US) • National Registry Annual Reports (2023)
Key Findings:
- Polished tapered cemented stems (Exeter V40, CPT, C-Stem AMT) are consistently among the best-performing femoral components, with all-cause revision around or below 5 percent at 15 years
- Registries report cemented femoral fixation has a LOWER revision rate than uncemented in patients over 75 years and reduced periprosthetic fracture in osteoporotic bone
- SHAR long-term data show Exeter and Charnley stems surviving approximately 88 to 90 percent at 25 years, validating durability of the cemented construct
- Registry signals (not single-centre series) detect implant-specific underperformers and underpin post-market surveillance worldwide
Clinical implication: Convergent international registry evidence - not a single country's data - establishes modern cemented polished-taper stems as a gold-standard femoral solution, especially in older patients and poor bone, and is the basis for evidence-based implant choice.
Evidence
The Swedish Total Hip Replacement Register
Malchau H, Herberts P, Eisler T, Garellick G, Soderman P • Journal of Bone and Joint Surgery (American) (2002)
Key Findings:
- Long-term national registry data from Sweden establishing the benchmark survival of cemented femoral stems
- Cemented Exeter and Charnley stems surviving approximately 88 to 90 percent at 25 years
- Demonstrated that cementing technique (restrictor, lavage, retrograde delivery, pressurization) is the dominant determinant of stem survival, more than implant brand
- Founded the registry methodology now used worldwide for implant post-market surveillance
Clinical implication: The registry that validated third-generation cementing principles at a population level and set the 25-year survival benchmark for the modern cemented femoral construct.
Evidence
The Well-Cemented Total Hip Arthroplasty: Theory and Practice
Breusch SJ, Malchau H • Berlin: Springer-Verlag (textbook) (2005)
Key Findings:
- Comprehensive textbook codifying modern cementing principles and the surgical technique for canal preparation
- Established vacuum mixing as a fourth-generation standard: porosity reduced 80 to 90 percent with fatigue strength improved 30 to 50 percent
- Detailed the canal-preparation protocol (the DRY BONE mnemonic) and the evidence-based approach to creating an optimal 2 to 3mm cement mantle
- Linked cement-mantle quality in each Gruen zone to long-term stem survival
Clinical implication: The reference text that systematised third and fourth-generation cementing into a reproducible operative technique, justifying the centralizer use and mandatory lateral radiographs still audited today.
Evidence
Safe management of cemented hemiarthroplasty for hip fracture (AAGBI Safety Guideline)
Association of Anaesthetists of Great Britain and Ireland / British Orthopaedic Association • London: AAGBI (2015)
Key Findings:
- National multidisciplinary safety guideline for cemented arthroplasty in the frail elderly
- Establishes the mandatory pre-cementing surgeon-anaesthetist communication step and haemodynamic optimisation
- Recommends thorough lavage and gentle (not forceful) pressurisation to reduce bone cement implantation syndrome
- Provides risk stratification for cemented arthroplasty in hip fracture patients
Clinical implication: The operative-anaesthetic safety standard that operationalises BCIS prevention - the pre-cement time-out, fluid loading and gentle pressurisation practised on every cemented case.