The emergence of personalized medicine and penetration of many technologies is adding to the uncertainty of global health economy – thereby compelling healthcare organizations to plan their future moves. The products and technologies surrounding orthopedic implants, in particular, are rapidly evolving. The digital revolution is taking hold in line with surgeons benefiting from the incorporation of robotic-guidance systems. Additionally, orthopedic surgery is on a path towards minimally invasive and highly precise operations, with a greater proportion of outpatient procedures. Today, as accuracy and comparable approaches take the front seat in the assessment of the quality of care and outcomes, new tools and techniques are entering the field of orthopedics.
The technology underlying long-term stability of fixation in bone achieved with cemented anchorage has matured significantly since its first usage in the 1940s, which was to close gaps in the human skull. Today, key advantages of bone cemented prosthesis depends on the optimal primary fixation between bone and implant, and subsequently in a faster patient recuperation. Well adapted to bone complex cavities, bone cement had long been a gold standard in the field of joint replacement. However, several shortcomings such as long-term prosthesis loosening and the potential breakdown of cement, side effects, and toxicity of bone cement are being effectively addressed recently. Moreover, the use of bone cement is marginally reduced with the advent of cementless or press-fit implant that encourages the natural bone to grow onto it.
The fourth generation of cementing techniques
The first generation of cementing techniques involved the hand mixing of cement in a bowl – a rudimentary process, and long-term results for cemented implants are not impressed by today’s standards. Significant improvements have been made during the evolution from first to third generation of cementing techniques; from hand mixing to vacuum centrifugation.
With substantially increased knowledge regarding cement properties and the impact of bone preparation on the bone-cement interface, challenges associated with porosity were reduced and the importance of desirable cement mantle around the prosthesis was clearly understood. This had further led to development of the fourth generation of cementing techniques that involves the use of proximal and distal stem centralisers to insert prosthesis, ensuring an even cement mantle. These centralizers have increased the likelihood of achieving a complete cement mantle to reproduce. Additionally, in vitro experiments of distal and proximal centralizers have demonstrated improved bone penetration and higher interface of shear-strengths with low-viscosity cement.
Rise of minimally invasive surgeries to impact application
In recent years, medical and technological developments such as robot-assisted surgery, 3D bioprinting, and Artificial Intelligence (AI) in healthcare have had a profound effect on orthopedic surgical procedures. Patients are increasingly demanding less invasive surgical techniques for much better outcomes and shorter hospital stays. Consequently, more attention is being paid to the development of a new generation of injectable and digitally applicable bone cement that is not only bioactive, biodegradable, and have excellent mechanical properties, but also compatible with newer surgical techniques.
For instance, in vertebroplasty – an effective, minimally invasive procedure for treating spinal fractures due to osteoporosis – bone cement is slowly injected under pressure, where the amount of cement and pressure are closely monitored to avoid any leakage. In the case of kyphoplasty, a path into the bone is created with two tiny tubes containing small inflatable balloons that raise the vertebrata to appropriate height. The cavities formed post removal of these balloons are filled with bone cement, which significantly reduces the potential risk of cement leakage.
The degree of interdigitation of bone cement is significantly influenced by its rheological properties. Its optimum penetration into cancellous bone structure remains paramount to achieve adequate load transfer across different interfaces. While an increasing number of research studies continue to focus on nanoparticle additives and enhanced bone cement interface, the convergence of surgical procedures with robotic technologies will call for advancements in the robo-guided insertion of bone cement.