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BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
A Biomechanical Analysis
of Polyethylene Liner
Cementation into a Fixed
Metal Acetabular Shell
BY GEOFFREY F. HAFT, MD, ANNELIESE D. HEINER, PHD, LAWRENCE D. DORR, MD,
THOMAS D. BROWN, PHD, AND JOHN J. CALLAGHAN, MD
Investigation performed at the Departments of Orthopaedic Surgery and Biomedical Engineering, University of Iowa, Iowa City, Iowa
Background: A common clinical scenario encountered by an orthopaedic surgeon is a patient with a secure cementless acetabular shell and a failed polyethylene liner. One treatment option is to cement a new liner into the fixed
shell. The purpose of this study was to evaluate technical variables to improve the mechanical strength of such cemented liner constructs.
Methods: The contributions of shell texturing, liner texturing, and cement mantle thickness (between the liner and
the shell) were evaluated by comparing torsional strength (among nine groups of constructs) and lever-out strength
(among eight groups of constructs).
Results: Failure almost always occurred at the cement-liner interface. The two exceptions (failure at the shell-cement
interface) occurred with a polished, untextured shell with no screw-holes. This finding indicates that if a shell has existing texturing (such as holes), further intraoperative scoring of the shell is unnecessary, but some sort of texturing
is necessary to avoid construct failure at the shell-cement interface. Textured liners had significantly ( = 0.05)
greater torsional and lever-out strength than untextured liners. The greatest construct strength occurred when liner
grooves were oriented so as to oppose the applied loading. A 4-mm-thick cement mantle resulted in slightly greater
torsional strength than a 2-mm-thick cement mantle, and a 2-mm-thick cement mantle resulted in considerably
greater lever-out strength than a 4-mm-thick cement mantle, but these differences were not significant.
Conclusions: When cementing a liner into a well-fixed shell, a surgeon should ensure that both the shell and the
liner are textured, as interdigitation of the cement with the shell and the liner is crucial to the mechanical strength of
this construct.
urgeons who perform total joint arthroplasty are frequently faced with a patient who has a cementless acetabular shell that is securely fixed to the pelvis but the
polyethylene liner has failed. Polyethylene wear and osteolysis
associated with a secure cementless acetabular shell are becoming frequent clinical problems, as better designs of the component last into the second decade1 and less optimal designs fail
earlier2-10. In addition to wear, another complication is dislodgment of the modular liner. Numerous case reports over the last
decade have established the ubiquity of this complication in association with a variety of acetabular components11-22.
Several options are available to the surgeon in this situation. One option is to perform a complete acetabular revision,
which may be the preferred treatment in patients who have
poor fixation of the acetabular shell, malpositioning of the
shell, or a very small shell in which a cemented liner would
unduly compromise the polyethylene thickness. However, complete revision of the acetabular component is accompanied by
serious potential complications, including pelvic discontinuity and severe bone loss. Typically, a 6 to 8-mm increase in the
diameter of the replacement acetabular shell is required with
this option, and cutting the original shell into pie-slice pieces
(with the potential for particulate debris generation) is sometimes necessary. Also, although revision acetabular components demonstrate stable interfaces at five to ten years, they
are more commonly associated with radiolucent lines than are
primary components23,24. Another option is simply to replace
the damaged or worn liner with a new version of the original.
However, there are several common situations in which this is
not an option: the locking mechanism of the liner may be
damaged, a replacement polyethylene liner may be unavailable
or of questionable quality (as a result of gamma irradiation in
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TABLE I Combinations of Shells and Liners Used in Torsion and Lever-out Testing*
Liners
Shells
Cluster hole-unscored
(Summit 54)
Smooth 2-mm
(Summit 50)
Smooth 3-mm
(Duraloc 48)
T, L (2.05 mm)
Cluster hole-scored
(Summit 54)
Smooth 4-mm
(Summit 46)
Vertically
Scored
(Summit 46)
Circumferentially
Grooved
and Nubbed
(Ultima 44)
T, L (4.05 mm)
T, L (4.05 mm)
T, L (3.24 mm)
T (4.05 mm)
T (3.24 mm)
Polished-no hole-unscored
(Duraloc 54)
T, L (3.15 mm)
T, L (3.20 mm)
Polished-no hole-scored
(Duraloc 54)
T, L (3.15 mm)
L (3.20 mm)
*Groups were chosen on the basis of component availability. Five replicate shells and liners were tested in each combination. The components are designated by name and size. Cement mantle thicknesses for shell-liner combinations are also shown (in parentheses). All implants were manufactured by DePuy Orthopaedics (Warsaw, Indiana). T = torsion testing, and L = lever-out testing.
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Fig. 1
Acetabular shells (top) and liners (bottom) used for torsional and lever-out testing of cemented liner constructs. The scoring simulated
intraoperative scratching that is done ostensibly to improve cement interdigitation; the channels are 2 mm wide and 1 mm deep. All
implants were manufactured by DePuy Orthopaedics.
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geneity and because it provides a conservative estimate of significance. The second method ignores variance heterogeneity
and thus provides a lower limit to the estimate of p. Statistical
power was calculated for = 0.05 for nine experimental
groups of five specimens each and for the realized effect sizes
and a benchmark effect size of one standard deviation37.
Lever-out Testing
Eight experimental groups, with five specimens in each for a total of forty specimens, were evaluated with lever-out testing.
The liners were attached to a 6.35-mm-thick (0.25-in) gripping
ring, with use of twelve small circumferentially spaced screws
(Fig. 3-A). A lever arm (a 3/8"-24 bolt) was screwed into the
center of the bearing surface, and a retaining nut was screwed to
the level of the ring. A low-melting-point (70C) bismuth alloy
(Cerrobend; Cerro Metal Products, Bellefonte, Pennsylvania)
was then poured into the liner. For the smooth 3-mm liners, the
vertically scored liners, and the circumferentially grooved and
nubbed liners, eight holes were drilled into the bearing surface
for interdigitation of the bismuth alloy, to improve purchase.
The specimen was then attached to the load cell of the materials
testing machine. Lever-out torque was applied by means of a
cylindrical platen eccentrically contacting the lever arm. The
platen was lowered at a rate of 1.33 mm/sec (corresponding to a
Fig. 2-A
Fig. 2-B
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Fig. 3-A
tion, power was 0.997 for the torsional measures and 0.995 for
the lever-out measures. For the actual one-way analyses of
variance, power was 1.000 for all four measures. Visible failure
occurred only at the cement-liner interface, with the exception
of only two specimens. The two exceptions were both polishedno hole-unscored shells; one involved failure of the shellcement interface with a circumferentially grooved and nubbed
liner, and the other was a combined failure of the cement-liner
and shell-cement interfaces with a smooth 3-mm liner. Because of differences in the design features among the implants,
not all cemented liner constructs could be directly compared;
therefore, only certain subsets are discussed below.
Effect of Shell Texturing
The groups were not compared with respect to the effect of
shell texturing because failure did not occur at the shellcement interface except in the two specimens discussed above.
As long as the shell had some type of texturing, whether existing features (screw-holes) or intraoperative scoring, no failure occurred at the shell-cement interface.
Effect of Liner Texturing
The effect of liner texturing was studied with the cluster holeunscored shells as a constant factor; the smooth 4-mm liners,
vertically scored liners, and circumferentially grooved and
nubbed liners were compared. In torsion, yield torque was
significantly higher for the vertically scored liners ( = 0.05)
(Fig. 4-A). Maximum torque was significantly higher ( =
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Fig. 3-B
0.05) for the two textured liners (the vertically scored liners
and the circumferentially grooved and nubbed liners), and
these two liners were not significantly different from one another (Fig. 4-A). In the lever-out test, the yield and maximum
moments were significantly higher for the circumferentially
grooved and nubbed liners ( = 0.05) (Fig. 4-B).
Effect of Cement Mantle Thickness
The effect of cement mantle thickness was studied with the
cluster-hole-unscored shell as a constant factor; the smooth
4-mm and smooth 2-mm liners were compared. In torsion,
yield and maximum torque were slightly higher for smooth
4-mm liners, but the difference was not significant (Fig. 5-A).
In the lever-out test, the yield moment for the 4-mm cement
mantle was a mean (and standard deviation) of 6.63 2.36
N-m, whereas the 2-mm cement mantle resisted with a mean
of 22.85 6.41 N-m (Fig. 5-B). The difference between the
means (16.2 N-m) did not meet the requirement of a mean
difference of 17.5 N-m for significance with use of the TukeyWelsch test. However, when the conventional Student twotailed t test was used, the p value was 0.0031. For the maximum
moment in the lever-out test, the 4-mm cement mantle resisted with a mean (and standard deviation) of 23.14 6.32
N-m, whereas the 2-mm cement mantle resisted with a mean
of 42.37 4.40 N-m (Fig. 5-B). The difference between these
means (19.2 N-m) also did not meet the requirement for a
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Fig. 4-A
Fig. 4-B
Effect of liner texturing in torsion testing (Fig. 4-A) and lever-out testing (Fig. 4-B). The cluster hole-unscored shell was common to all specimens in this evaluation. Asterisks indicate groups with significantly different average values ( = 0.05).
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Fig. 5-A
Fig. 5-B
Effect of cement mantle thickness in torsion testing (Fig. 5-A) and lever-out testing (Fig. 5-B). The cluster hole-unscored
shell was common to all specimens in this evaluation. No groups had significantly different average values ( = 0.05).
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ers would resemble the backside designs of cemented allpolyethylene acetabular components. The liners should have
vertical grooves to increase torsional strength at the cementliner interface and circumferential grooves to increase the
lever-out strength. The liners should also incorporate spacers to prevent bottoming out or malpositioning of the liner
in the shell; these spacers can also contribute to the strength
of the cement-liner interface. Trial liners, which the surgeon
can use to ensure a proper fit in a variety of shell types, are
also crucial. Along these lines, manufacturers should also
consider making a constrained liner with these characteristics, as the cemented liner technique is gaining popularity in
patients with recurrent dislocations26,27. Given the increasing
prevalence of patients who will require cemented acetabular liners in the coming years, the availability of a line of
prefabricated textured liners would be useful in revision hip
surgery.
Appendix
Results of cemented liner constructs tested in torsion
and lever-out are available with the electronic versions of
this article, on our web site at www.jbjs.org (go to the article
citation and click on Supplementary Material) and on our
quarterly CD-ROM (call our subscription department, at 781449-9780, to order the CD-ROM).
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Geoffrey F. Haft, MD
Thomas D. Brown, PhD
Department of Biomedical Engineering, University of Iowa, 2181
Westlawn Building, Iowa City, IA 52242. E-mail address for G.F.
Haft: geoff-haft@uiowa.edu. E-mail address for T.D. Brown:
tom-brown@uiowa.edu
Anneliese D. Heiner, PhD
John J. Callaghan, MD
Department of Orthopaedic Surgery, University of Iowa, 200
Hawkins Drive, Iowa City, IA 52242. E-mail address for J.J.
Callaghan: john-callaghan@uiowa.edu. E-mail address for A.D.
Heiner: anneliese-heiner@uiowa.edu
Lawrence D. Dorr, MD
The Dorr Arthritis Institute, Centinela Hospital Medical Center, 501
East Hardy Street, Suite 300, Inglewood, CA 90301. E-mail address:
centinela.appts@tenethealth.com.
In support of their research or preparation of this manuscript, one or
more of the authors received grants or outside funding from DePuy, Warsaw, Indiana. In addition, one or more of the authors received payments
or other benefits or a commitment or agreement to provide such benefits
from commercial entities (DePuy and Howmedica, Rutherford, New Jersey). Also, a commercial entity (DePuy) paid or directed, or agreed to pay
or direct, benefits to a research fund, foundation, educational institution,
or other charitable or nonprofit organization with which the authors are
affiliated or associated.
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