Cemented femur


Cemented femurCemented femur


Goals of femoral cementing


Standard method (i.e. Exeter)

Optimize cement-bone interface

Cement mantle free of defects

Femoral component centered in cement mantle

Minimum 2 mm thickness


French paradox

Describes the stem inserted "line to line"

a thin mantle is generated in cancellous bone during pressurising




Styker exeter stem SPECTRON

Stryker Exeter Stem  (taper-slip)                        Smith + Nephew Spectron (composite beam)



- double or triple taper shape

- no collar

- highly polished (Ra < 1 micrometer)

- allows controlled subsidence in mantle (~1-2mm)

- continuously loading bone via hoop stresses

- no fixation between cement and stem (cement well fixed to bone)


Composite beam

- matte finish

- cement fixation between cement and stem (as well as cement and bone)

- no subsidence

- collared



- Stainless steel 

- generate less particulate debris than titanium


Cement Issues


Cement mixing


Cement viscosity

- varying viscosity with different advantages

- low viscosity harder to handle early, but easier to inject (down a femur)

- high viscosity easier to handle

- no consensus in the literature regarding outcomes


Centrifugation / vacuum mixing

- reduces pore size

- stronger cement

- more resistant to fracturing

- reduces fumes



- pressurization increases penetration

- increases strength of cement-bone interface



- achieve more uniform cement mantle 

- especially in zone 5 & 6

- prevent stress riser of tip of stem on bone

- allow controlled subsidence in a polished, taper-slip stem


Cement Mantle

- crack incidence greatest when mantle < 2 mm

- varus stem results in thin cement mantle in proximal medial & distal lateral zones



- in relatively small doses effect on mechanical characteristics of PMMA negligible

- must be heat labile

- vancomycin / tobramycin / gentamicin


Cementing techniques



- finger-packing doughy cement



- cement restrictor

- cleaning with pulsatile lavage  

- cement inserted retrograde using cement gun 



- vacuum centrifuge

- pressurization of cement mantle


Barrack's femoral component cementation quality grading system


Grade Definition
A Complete filling of the medullary canal, without radiolucent lines between the cement and the bone (white-out)
B Radiolucent line covering up to 50% of the cement-bone interface
C Radiolucent line covering between 50% and 99% of the cement-bone interface or incomplete cement mantle
D Complete radiolucent line (100%) at the cement-bone interface and/or absence of cement distally to the end of the stem


THR Type 1 Cemented FemurType 2 Cemented FemurTHR Type 3 Cemented FemurTHR Type 3b Cemented Femur

Grade A                                    Grade B                                      Grade C                                 Grade D




Stryker Exeter surgical technique PDF


Zimmer CPT surgical technique PDF




Australian Joint Registry 2023 Revision rates by fixation (400,000 THA)


  Cemented Uncemented Hybrid
5 year 2.6 3.0 2.6
10 year 3.8 4.3 3.9
15 year 5.1 5.9 5.3
20 year   7.0 6.7


15 year revision rate by age



64 - 74 year                                                                                  > 75 years


  Cemented Uncemented Hybrid
< 55   6.4 7.2
55 - 64 6.2 5.5 6.1
65 - 74 5.4 5.5 5.2
> 75 3.3 6.8 4.7






Harris Categories of Cemented Femoral Stem Loosening

Definitely Loose Probably Loose Possibly Loose

Change in stem position


Cement mantle fracture


Radiolucent line > 1 mm

Lucencies at cement implant interface


Endosteal scalloping

Radiolucent lines at cement/bone interface

Cemented Femur Definitely LooseCemented Femur Probably LooseCemented Femur Possibly Loose

Definitely                                        Probably                                                           Possibly