title: [Significance of bone mineral density and modern cementing technique for in vitro cement penetration in total shoulder arthroplasty].
abstract: OBJECTIVE
  Loosening of the glenoid component is one of the major causes of failure in total shoulder arthroplasty. Possible risk factors for loosening of cemented components include an eccentric loading, poor bone quality, inadequate cementing technique and insufficient cement penetration. The application of a modern cementing technique has become an established procedure in total hip arthroplasty. The goal of modern cementing techniques in general is to improve the cement-penetration into the cancellous bone. Modern cementing techniques include the cement vacuum-mixing technique, retrograde filling of the cement under pressurisation and the use of a pulsatile lavage system. The main purpose of this study was to analyse cement penetration into the glenoid bone by using modern cement techniques and to investigate the relationship between the bone mineral density (BMD) and the cement penetration. Furthermore we measured the temperature at the glenoid surface before and after jet-lavage of different patients during total shoulder arthroplasty. It is known that the surrounding temperature of the bone has an effect on the polymerisation of the cement. Data from this experiment provide the temperature setting for the in-vitro study.
  
  
  METHODS
  The glenoid surface temperature was measured in 10 patients with a hand-held non-contact temperature measurement device. The bone mineral density was measured by DEXA. Eight paired cadaver scapulae were allocated (n = 16). Each pair comprised two scapulae from one donor (matched-pair design). Two different glenoid components were used, one with pegs and the other with a keel. The glenoids for the in-vitro study were prepared with the bone compaction technique by the same surgeon in all cases. Pulsatile lavage was used to clean the glenoid of blood and bone fragments. Low viscosity bone cement was applied retrogradely into the glenoid by using a syringe. A constant pressure was applied with a modified force sensor impactor. Micro-computed tomography scans were applied to analyse the cement penetration into the cancellous bone.
  
  
  RESULTS
  The mean temperature during the in-vivo arthroplasty of the glenoid was 29.4 °C (27.2-31 °C) before and 26.2 °C (25-27.5 °C) after jet-lavage. The overall peak BMD was 0.59 (range 0.33-0.99) g/cm (2). Mean cement penetration was 107.9 (range 67.6-142.3) mm (2) in the peg group and 128.3 (range 102.6-170.8) mm (2) in the keel group. The thickness of the cement layer varied from 0 to 2.1 mm in the pegged group and from 0 to 2.4 mm in the keeled group. A strong negative correlation between BMD and mean cement penetration was found for the peg group (r (2) = -0.834; p < 0.01) and for the keel group (r (2) = -0.727; p < 0.041). Micro-CT shows an inhomogenous dispersion of the cement into the cancellous bone.
  
  
  CONCLUSIONS
  Data from the in-vivo temperature measurement indicate that the temperature at the glenohumeral surface under operation differs from the body core temperature and should be considered in further in-vitro studies with human specimens. Bone mineral density is negatively correlated to cement penetration in the glenoid. The application of a modern cementing technique in the glenoid provides sufficient cementing penetration although there is an inhomogenous dispersion of the cement. The findings of this study should be considered in further discussions about cementing technique and cement penetration into the cancellous bone of the glenoid.
authors.affiliation: Sektion Obere Extremität: Schulter-, Ellenbogen- und Handchirurgie, Orthopädische Universitätsklinik Heidelberg. guido.pape@med.uni-heidelberg.de
authors.forename: G
authors.initials: G
authors.lastname: Pape
authors.forename: P
authors.initials: P
authors.lastname: Raiss
authors.forename: K
authors.initials: K
authors.lastname: Kleinschmidt
authors.forename: C
authors.initials: C
authors.lastname: Schuld
authors.forename: G
authors.initials: G
authors.lastname: Mohr
authors.forename: M
authors.initials: M
authors.lastname: Loew
authors.forename: M
authors.initials: M
authors.lastname: Rickert
mesh_terms: D000268:Adhesiveness; D000328:Adult; D000368:Aged; D019643:Arthroplasty, Replacement / Q000379:methods*; D001831:Body Temperature; D002484:Cementation / Q000379:methods*; D005260:Female; D006801:Humans; D007595:Joint Prosthesis; D008297:Male; D008875:Middle Aged; D012785:Shoulder Joint / Q000503:physiopathology* / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult