Factors influencing pressurization of the femoral canal during cemented total hip arthroplasty

Successful cement pressurization with total hip arthroplasty depends on the capacity of the cement gun and its ability to pressurize the canal and the integrity of the intramedullary plug and the proximal seal used to contain the cement bolus during pressurization. In the laboratory, the authors measured the volume of cement delivered by two cement guns (from Zimmer, Warsaw, IN, and Howmedica, Rutherford, NJ) in comparison with typical values for the volume of the medullary canal following standard surgical preparation. The two cement guns studied delivered 93 and 138 mL cement, respectively. In comparison, the volume of the intramedullary canal ranged from 35 to 70 mL using a standard femoral prosthesis (Precision Hip System, Howmedica). Peak pressures developed during cement injection using the cement guns were 73.6 +/- 27.1 psi for the Zimmer system and 47.3 +/- 16.9 psi for the Howmedica system. Both devices were able to sustain a minimum pressure of at least 6.5 psi through cementing when used in conjunction with a flexible pressurizing seal. The mechanical performance of five designs of intramedullary plugs was assessed by monitoring plug displacement during cement pressurization in reamed cortical specimens. The performance of each device was judged by its ability to withstand cement pressures of 50 psi without displacement within the medullary canal. On the basis of this test, the probability that these plugs would exceed this criterion when used with the femur was estimated to range from 24 to 94%. Few of the commercially available plugs were able to withstand cement pressures routinely generated using standard cement delivery systems.