4.
Mixing:
The Benefit of Vacuum Mixing
Jian-Sheng Wang
Summary
Vacuum mixing of bone cement has been used in ce-
mented hip-joint replacement procedures for over two de-
cades. Although literature on bone cement is voluminous,
relatively few studies have reported the effects of vacu-
um-mixing methods on the cemented hip replacement.
While it has been proven that vacuum mixing improves
the mechanical properties of bone cement, other effects
need to be clarified. This chapter discusses the effects of
vacuum mixing on cement quality, cement homogeneity,
the cement-prosthesis interface and the operating room
environment. It also discussed vacuum mixing in terms of
bone-cement shrinkage and antibiotic release in total hip
replacements.
Introduction
Until the 1980s, the composition and preparation of bone
cement had not changed from the standards introduced
by Charnley back in 1959. Then, in the 1980s, techniques
for improving cement strength began to be investigated.
Closed mixing under vacuum was developed initially for
environment reasons, but its benefits in terms of pro-
ducing homogenous cement, enhancing the mechanical
properties of cement, improving cementing technique
as well as safeguarding the operating room environment
soon became evident.
In order to improve the mechanical properties of
bone cement and thereby reduce the risk of cement
failure in arthroplasties, substantial efforts have been
invested into the development of new techniques for
bone cement mixing and delivery applications with the
objective of reducing macro- and microporosity. These
techniques have the net effect of improving the overall
quality of the cement.
Numerous studies have shown that, compared to oth-
er mixing methods, vacuum mixing reduces monomer
evaporation and exposure in the operating room. Fur-
thermore, it prevents air entrapment in cement, reduces
cement porosity, decreases the number of unbounded
particles in cement and increases the cements mechanical
strength. Clinical observations have revealed that vacuum
mixing of bone cement improves mid- and long-term
survival rates of total hip implants [41].
This chapter focuses on the effect of vacuum mixing
on the characteristics and the quality of bone cement used
in arthroplasty.
The Evolution of Cement Mixing Systems
When bone cement was first used in arthroplasty, it was
hand-mixed in a bowl in the operating room and then in-
serted by hand or transferred and injected into the desired
location. Because PMMA comes as a powder composed
of prepolymerised particles to be mixed with the liquid
monomer, monomer fumes release into the air. Further-
more with hand mixing, a certain amount of porosity
in the final material, even in lower viscosity cements, is
unavoidable owing to air entrapment.
During the 1980s different vibrating mixing tech-
niques were introduced in the hope of improving mixing
and thereby bone cement properties [37]. The results,
however, were not convincing. While Burke et al. [9]
reported an increase in the cements fatigue life and
ultimate tensile strength when centrifugation was used,
a phenomenon they attributed to a reduction in the
number and size of pores, Rimnace et al. [49] found no
 108 Part II Basic Science

improvement in the static or dynamic properties of sever-
al brands of bone cement when mixed by centrifugation.
The results seemed to vary significantly depending on the
type of centrifugation and cement used, and the cement
was not consistently homogenous. Moreover, antibiotics
and radiographic contrast media tended to gather in the
periphery of the mix, and the upper volume of the cement
often became more porous than the rest of the cement.
At about the same time as vibration and centrifuga-
4 tion were being developed and tested, closed mixing
under vacuum was introduced [4, 35, 36]. After some
refining, it produced better results than centrifugation,
which was soon thereafter abandoned in favour of vac-
uum mixing, particularly because of the ease of delivery
when using cartridge mixing. Today, vacuum mixing is
widely accepted as the method of choice for achieving
homogenous cement, reducing porosity and increasing
cement strength, which is why it is an integral part of
Modern Cementing Technique [40].
container to delivery system [11, 43, 62, 69]. Conventional
mixing of bone cement produces porosity of 516%.
Vacuum mixing produces porosity of 0.11% [38, 65].
Relationship Between Porosity and Fatigue
Property of Cement
Porosity has been found to be the major cause of de-
creased mechanical strength and fatigue life of bone
cement. To ensure its in vivo survival, the cement must
be able to withstand the varying loads it endures. Thus
fatigue property, which is directly affected by porosity, is
as important in determining the long-term survival of a
joint replacement as static strength.
Fatigue failure occurs when cement cracks are initi-
ated as a result of defects in the cement mantle. It is the
presence of large voids within the cement that leads to
a rapid propagation of fracture ( Fig. 4.1a). Secondary
cracks develop along the small pores ( Fig. 4.1b). Such

Improvement of Environment

MMA is a toxic, highly volatile organic solvent. Cytotoxic

effects on human fibroblasts in culture media have been
described and attributed to MMA [57]. It is now known
that the adverse effects of working with MMA include
local mucosal irritation i.e., irritation of the respiratory
system, eyes and skin contact sensitivity that may lead
to toxic dermatitis [20, 31, 33, 47]. Indications are head-
ache, nausea and lack of appetite. MMA is not thought to
be carcinogenic to humans under normal conditions of
use. However, techniques should be employed to reduce
medical staff exposure to MMA during cemented implan-
tation. Operating staff should avoid direct contact with
MMA, and room ventilation should be optimised.
Monomer exposure is regulated by law in many coun- a
tries. The exposure limits range from 50100 ppm in dif-
ferent countries in Europe. The exposure of conventional
mixing in open bowl is about 10 ppm in the breathing
zone [8]. Vacuum mixing systems reduce the exposure
by 5070% [53] and eliminate contact with bone cement
during delivery [6, 8, 12, 19, 53]. The working environ-
ment for the operating staff is improved, and the risk of
fume-induced headaches, respiratory irritation and aller-
gic reactions becomes minimal.

Improvements in Cement Quality

Porosity
b

Pores and voids of different sizes in cement are caused by Fig. 4.1a,b. SEM micrograph of fatigue fracture surface. a A large
air from the polymer powder. The air becomes trapped in pore causes stress concentration and initiates crack [27]. b Secondary
the cement during mixing and transferring from mixing crack associated with pores [56]
Chapter 4.1 Mixing: The Benefit of Vacuum Mixing
109 4

fractures are commonly observed in vitro and in vivo [10,
27, 30, 45, 56]. Because of stress concentration, the initial
crack is likely to start in an area of weakness or at a void
in the material [29]. Evidence of this cracking has been
found when examining retrieved cement [30, 56].
The reduction of porosity prevents or at the very least
retards the initiation of fatigue propagation. It is known
that vacuum mixing of cement increases mechanical
properties [4, 5, 13, 35, 36, 38, 69] largely as a result of
decreasing micro- and macropores [62, 66]. Numerous
studies have confirmed that vacuum mixing enhances
the fatigue life of the bone cement [17, 23, 34, 43, 45, 52,
65, 67, 70].
Cement Homogeneity
Bulk form PMMA cement exhibits good biocompatibility
when implanted in bone. However, in particulate form,
PMMA can evoke a foreign body and chronic inflamma-
tory reaction similar to that seen around loose cemented
arthroplasties [1, 22, 32, 55, 68].
Incomplete mixing of the monomer and polymer may
lead to partially united and, in some cases, free unbonded
cement particles. Vacuum mixing of bone cement not
only decreases the number of voids but also improves the
microscopic homogeneity of Palacos R cement [64]. Elec-
tronic microscopy shows that voids located on the surface
of cement as well as on the fracture surface of cement
invariably contain partially polymerised PMMA particles
and contrast media particles, such as zirconium dioxided
particles ( Fig. 4.2). When cement fracture occurs, less
homogeneous cement may release a larger number of
PMMA spheres and contrast media particles to the bone-
cement interface. These particles may evoke a foreign
body response or stimulate osteoclast activity [50 ,51, 68],
leading to osteolysis of the surrounding bone.
Cement-Prosthesis Interface
Studies have indicated that mechanical loosening of ce-
mented implants originates at the stem-cement interface
[28, 30, 60]. Loosening of the cemented stem further
increases stress in the cement mantle [24, 59]. Extensive
porosity at the cement-stem interface has been found
in retrieved cement mantles and in laboratory-prepared
specimens [7, 28] ( Fig. 4.3).
This interface porosity is caused by entrapment of air
at the stem surface during stem insertion and by residual
porosity in the cement. A further cause is the cements
shrinkage away from the colder stem surface which pro-
duces pores [7]. Although cement curing is chemically
initiated, polymerisation is thermally activated. Thus
cement curing starts at the warmer bone surface and pro-
gresses towards the cooler stem. Resultant pores as well as
residual pores in the cement are driven towards the last
polymerising region on the stem.
When cement is mixed under vacuum, cement poros-
ity is significantly reduced, producing less porosity at the
cement-prosthesis interface [7, 61] ( Fig. 4.4). Various stud-
Fig. 4.3. In SEM numerous small voids are present on the cement
surface at the prosthesis interface [30]

Fig. 4.2. Void on a fracture surface (left) and void located on the surface (right) of a Palacos R cement rod prepared at atmospheric pressure.
Many partially unpolymerised PMMA particles and zirconium dioxide particles are seen in the voids [64]
 110 Part II Basic Science
Fig. 4.4. Samples from a cemented implant. The cement was mixed at atmospheric pressure (left), and under vacuum (right). M metal; BC bone
cement
ies have shown that interface porosity affects the debonding
energy of the interface [43], weakens the resistance of the
cement to torsional load [15] and decreases fatigue life
of the cement-metal interface [26]. Interface porosity has
also been linked to the initiation of cement cracks [28, 30,
58]. The evidence is convincing that reduction of interface
porosity improves the strength of the interface, thereby
increasing the longevity of cemented implants.
Shrinkage
Cement has 35% volumetric shrinkage after curing [11].
Concerns over this shrinkage have focused primarily on
the stability of the implant. With vacuum mixing, the volu-
metric shrinkage may be increased from 35% to 57% in
different cements [44]. In a cemented hip stem, for exam-
ple, the cement grout is along the stem with a long cement
mantle (150200 mm) and thin cement layer (24 mm).
The shrinkage occurs more along the longitudinal axis
rather than diametrically [14], and it is the diametrical
shrinkage that may influence the cement interface. Studies
have been unable to find differences in diametrical shrink-
age or gap formation between cement and prosthesis when
a reduced porosity cement is used [14, 63]. Shrinkage,
however, within the cancellous bone bed can be regarded
as beneficial ( chapter 3.6), as some interface gaps allow
for re-vascularisation [16]. Vacuum mixing of cement has
not been found to negatively affect interface strength be-
tween cement and prosthesis. RSA ( chapter 7.3) showed
a stable cemented implant in early and middle term studies
of vacuum-mixed cemented implants [2, 48].
Antibiotic Release
While vacuum mixing reduces the porosity of bone cement,
it is thought that the process may adversely affect antibiotic
release ( chapter 3.1). Surgeons understandably are con-
cerned about the extent to which the mixing procedure
affects the release of antibiotics from the cement. Studies
have shown that the concentrations of several antimicro-
bial agents from antibiotic-loaded bone cement exceed
those obtained by systemic administration [21] as well as
the minimal inhibitory concentrations of several pathogens
according to the National Committee for Clinical Labora-
tory Standards breakpoints lasting from 338 days [3]. Vac-
uum mixing of gentamicin-loaded bone cements has been
shown to effectively reduce the number and size of cement
pores with only a minor reduction in antibiotic release [46].
The Norwegian Arthroplasty Register [18] documents the
best results occurring when antibiotic prophylaxis is ad-
ministered both systemically and with bone cement con-
taining antibiotics prepared under vacuum.
Clinical Significance
The aetiology of aseptic loosening of total joint arthroplas-
ties appears to be multifactorial, with surgical technique,
cementing technique, cement quality, cement viscosity,
prosthesis design, wear debris, joint fluid pressure and
micromotion all being involved. Although improved sur-
gical techniques have increased the probability of prosthe-
sis survival, reducing or eliminating bone cement fracture
by improving its material strength will further enhance
the longevity of cemented prostheses.
The affects of porosity reduction on the longevity
of the cement mantle and on the survival rate of a joint
replacement are still debated. In favour of porosity reduc-
tion is the fact that no direct clinical evidence has ever
shown an association between reduced survival rates and
porosity reduction [39]. Janssen et al. [29] explain the
apparent contradiction of porosity by means of a finite
element model showing that when stresses are distributed
homogenously in cement, pores act as crack initiators;
Chapter 4.1 Mixing: The Benefit of Vacuum Mixing
whereas under inhomogeneous stress conditions, crack
formation is governed by local stress intensities. The study
suggests that mechanical failure of cemented femoral
components is initiated in areas where stress concen-
trations are generated. Therefore, the effect of reduced
porosity on the failure mechanism in these areas will be
limited and clinically detectable only in large studies.
It remains clear, however, that with pores located in
areas of high stress concentrations, the cement mantle
will fail rapidly. The Swedish Hip Register gives a risk
ratio of vacuum mixing to revision of 0.74 after five years
from implantation [41], suggesting that vacuum mixing
improves the mid- to long-term survival rate of THA sig-
nificantly as compared to hand mixing. With 25 years of
clinical experience, Harris [25] indicated that in a cement-
ed total hip replacement, bone cement can be made five
times stronger just by porosity reduction. Various studies
indicate that macropores increase the risk of fatigue fail-
ure, and the current opinion is that efforts should be made
to minimise the number and size of macropores.
Take Home Messages
I I
Vacuum mixing significantly reduces macro- and
micropores in bone cement, thereby enhancing
the cements mechanical strength.
Vacuum mixing also improves cement homogeneity
and strengthens the cement-prosthesis interface.
Closed vacuum-mixing systems reduce the risk of
monomer exposure to operating room staff.
The slight bone cement shrinkage that occurs has
not been shown to adversely affect prosthesis
stability in any way. Nor does vacuum mixing have
a significant effect on effective antibiotic release.
A well-fixed cemented implant requires strong
cement to support the various loads it endures over
a prolonged period; only vacuum-mixed cement
seems to provide this kind of enduring strength.
References
1. Abbas S, Clohisy JC, Abu-Amer Y (2003) Mitogen-activated protein
(MAP) kinases mediate PMMA-induction of osteoclasts. J Orthop
Res 21(6):10418
2. Adalberth G, Nilsson KG, Kattholm J, Hassander H (2002) Fixation
of the tibial component using CMW-1 or Palacos bone cement
with gentamicin: similar outcome in a randomized radiostereo-
metric study of 51 total knee arthroplasties. Acta Orthop Scand
73(5):5318
3. Adam K, Couch L, Cierny G, Calhoun J, Mader JT (1992) In vitro and
in vivo evaluation of antibiiotic-impregnated polymethylmethacry-
late beads. Clin Orthop 278:24452
4. Alkire M, Dabezies E, Hastings P (1987) High Vacuum As a Method
of Reducing Porosity of Polymethylmethacrylate. Othopaedics
10:153339
5. Askew MJ, Kufel MF, Fleissner Jr PR, Gradisar Jr IA, Salstrom SJ, Tan
J (1990) Effect of vacuum mixing on the mechanical properties of
111 4
antibiotic-impregnated polymethylmethacrylate bone cement. J
Biomed Mater Res 24:57380
6. Bettencourt A, Calado A, Amaral J, Vale FM, Rico JM, Monteiro
J, Castro M (2001) The influence of vacuum mixing on methyl-
methacrylate liberation from acrylic cement powder. Int J Pharm
219:8993
7. Bishop NE, Ferguson S, Tepic S (1996) Porosity reduction in bone
cement at the cement-stem interface. J Bone Joint Surg (Br)
78(3):34956
8. Buchhorn GH, Streicher RM, Willert HG (1992) Exposure of surgical/
orthopedic operating room personnel to monomer vapors during
the use of bone cements--review of the literature and report of
experiences. Biomed Tech (Berl) 37:293302
9. Burke D, Gates E, Harris W (1984) Centrifugation as a method of
improving tensile and fatigue properties of acrylic bone cement. J
Bone Joint Surg (Am) 66:126573
10. Carter DR, Gates EI, Harris WH (1982) Strain controlled fatigue of
acrylic bone cement. J Biomed Mater Res 16:647657
11. Charnley J (1970) Low friction arthroplasty of the hip: theory and
practice. Springer, Berlin Heidelberg New York
12. Darre E, Gottlieb J, Nielsen PM, Jensen JS (1988) A method to deter-
mine methylmethacrylate in air. Acta Orthop Scand 59:2701
13. Davies JP, Harris WH (1990) Optimization and comparison of
three vacuum mixing systems for porosity reduction of Simplex P
Cement. Clin Orthop 254:26169
14. Davies JP, Harris WH (1995) Comparison of diametral shrinkage
of centrifuged and uncentrifuged Simplex P bone cement. J Appl
Biomater 6(3):20911
15. Davies JP, Kawate K, Harris WH (1995) Effect of interfacial porosity on
the torsional strength of the cement-metal interface. 41st Annual
Meetting Orthopedic Research Society, Orlando, FL, USA, p 713
16. Draenert K, Draenert Y, Garde U, Ulrich C (1999) Manual of cement-
ing technique. Springer, Berlin, Heidelberg, New York, Tokyo,
pp 2628
17. Dunne N-J, Orr J (2001) Influence of mixing techniques on the physi-
cal properties of acrylic bone cement. Biomaterials 22:181926
18. Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin
LI (2003) Antibiotic prophylaxis in total hip arthroplasty: effects
of antibiotic prophylaxis systemically and in bone cement on the
revision rate of 22,170 primary hip replacements followed 014
years in the Norwegian Arthroplasty Register. Acta Orthop Scand
74(6):64451
19. Eveleigh R (2002) Fume levels during bone cement mixing. Br J
Perioper Nurs 12(4):1457, 14950
20. Fregert S (1983) Occupational hazards of acrylate bone cement in
orthopaedic surgery. Acta Orthop Scand 54:7879
21. Frommelt L (2001) Gentamicin release from PMMA bone cement:
mechanism and action on bacteria. In: Walenkamp GHIM, Murray
DW (eds) Bone cement and cementing technique. Springer, Berlin
Heidelberg New York Tokyo
22. Goodman SB, Fornasier VL, Kei J (1988) The effects of bulk ver-
sus particulate polymethylmethacrylate on bone. Clin Orthop
(232):25562
23. Harper EJ, Bonfield W (2000) Tensile characteristics of ten com-
mercial acrylic bone cements. J Biomed Mater Res (Appl Biomater)
53:60516
24. Harrigan TP, Harris WH (1991) A three-dimensional non-linear finite
element study of the effect of cement-prosthesis debonding in
cemented femoral total hip components. J Biomech 24(11):1047
58
25. Harris WH (1992) The first 32 years of total hip arthroplasty. One
surgeons perspective. Clin Orthop (274):611
26. Iesaka K, Jaffe WL, Kummer FJ (2003) Effects of preheating of hip
prostheses on the stem-cement interface. J Bone Joint Surg Am
85(3):4217
27. James SP, Jasty M, Davies J, Piehler H, Harris WH (1992) A frac-
tographic investigation of PMMA bone cement focusing on the
 112 Part II Basic Science
relationship between porosity reduction and increased fatigue life.
J Biomed Mater Res 26:65162
28. James SP, Schmalzried TP, McGarry FJ, Harris WH (1993) Extensive
porosity at the cement-femoral prosthesis interface: a preliminary
study. J Biomed Mater Res 27(1):718
29. Janssen DW, Stolk J, Verdonschot N (2004) Why would cement
porosity reduction be clinically irrelevant, while experimental
data show the contrary? 50th Annual Meeting of the Orthopaedic
Research Society. San Francisco, USA, p 3
30. Jasty M, Maloney WJ, Bragdon CR, OConnor DO, Haire T, Harris WH
(1991) The initiation of failure in cemented femoral components of
hip arthroplasties. J Bone Joint Surg (Br) 73(4):5518
4 31. Jensen JS, Trap B, Skydsgaard K (1991) Delayed contact hypersen-
sitivity and surgical glove penetration with acrylic bone cements.
Acta Orthop Scand 62:2428
32. Johanson NA, Bullough PG, Wilson PD Jr., Salvati EA, Ranawat CS
(1987) The microscopic anatomy of the bone-cement interface in
failed total hip arthroplasties. Clin Orthop (218):12335
33. Leggat PA, Kedjarune U (2003) Toxicity of methyl methacrylate in
dentistry. Int Dent J 53(3):12631
34. Lewis G (1997) Properties of Acrylic Bone Cement: State of Art
Review. J Biomed Mater Res (Appl Biomater) 38:15582
35. Lidgren L, Bodelind B, Mller J (1987) Bone cement improved by
vacuum mixing and chilling. Acta Orthop Scand 57:2732
36. Lidgren L, Drar H, Moller J (1984) Strength of polymethylmethac-
rylate increased by vacuum mixing, Acta Orthop Scand 55(5):536
41
37. Lindn U (1991) Mechanical properties of bone cement. Impor-
tance of the mixing technique. Clin Orthop 272:2748
38. Linden U, Gillquist J (1989) Air inclusion in bone cement. Impor-
tance of the mixing technique. Clin Orthop 247:14851
39. Ling RS, Lee AJ (1998) Porosity reduction in acrylic cement is clini-
cally irrelevant. Clin Orthop 355:24953
40. Malchau H, Herberts P (1996) Prognosis of total hip replacement;
surgical and cementing technique in THR: a revision-risk study of
134 056 primary operations. 63rd Annual Meeting of the AAOS,
February 2226, Atlanta, USA
41. Malchau H, Herberts P (2000) Prognosis of total hip replacement.
65th Annual Meeting of the AAOS. March 1519, Orland, USA
42. Mann KA, Damron LA, Race A, Ayers DC (2004) Early cementing
does not increase debond energy of grit blasted interfaces. J
Orthop Res 22(4):8227
43. Mau H, Schelling K, Heisel C, Wang JS, Breusch SJ (2004) Compari-
son of different vacuum mixing systems and bone cements with
respect to reliability, porosity and bending strength. Acta Orthop
Scand 75:16072
44. Muller SD, Green SM, McCaskie AW (2002) The dynamic volume
changes of polymerising polymethyl methacrylate bone cement.
Acta Orthop Scand 73(6):6847
45. Murphy BP, Prendergast PJ (2002) The relationship between stress,
porosity, and nonlinear damage accumulation in acrylic bone
cement. J Biomed Mater Res 59(4):64654
46. Neut D, van de Belt H, van Horn JR, van der Mei HC, Busscher HJ
(2003) The effect of mixing on gentamicin release from polymeth-
ylmethacrylate bone cements. Acta Orthop Scand 74:6706
47. Nissen JN, Corydon L (1985) Corneal ulcer after exposure to vapours
from bone cement (methyl methacrylate and hydroquinone). Int
Arch Occup Environ Health 56(2):1615
48. Nivbrant B, Karrholm J, Rohrl S, Hassander H, Wesslen B (2001) Bone
cement with reduced proportion of monomer in total hip arthro-
plasty: preclinical evaluation and randomized study of 47 cases
with 5 years follow-up. Acta Orthop Scand 72(6):57284
49. Rimnace CM, Wright TM, McGill DL (1986) The effect of centrifuga-
tion on the fracture properties of acrylic bone cements. J Bone
Joint Surg (Am) 68:2817
50. Sabokbar A, Fujikawa Y, Murray DW, Athanasou NA (1997) Radio-
opaque agents in bone cement increase bone resorption. J Bone
Joint Surg (Br) 79:12934
51. Sabokbar A, Murray DW, Athanasou NA (2001) Osteolysis induced
by radio-opaque agents. In Bone cements and cementing tech-
niques Springer, Berlin Heidelberg, pp 14961
52. Schelling K, Breusch SJ (2001) Efficacy of a new prepacked vacuum
mixing system with Palamed G bone cement. In: Walenkamp GHIM,
Murray DW (eds) Bone cement and cementing technique. Springer,
Berlin Heidelberg New York Tokyo, pp 97107
53. Schlegel UJ, Sturm M, Ewerbeck V, Breusch S (2004) Efficacy of
vacuum bone cement mixing systems in reducing methylmeth-
acrylate fume exposure: comparison of 7 different mixing devices
and handmixing. Acta Orthop Scand;75(5):55966
54. Schreurs BW, Spierings PT, Huiskes R, Slooff TJ (1988) Effects of
preparation techniques on the porosity of acrylic cements. Acta
Orthop Scand 59:4039.
55. Shardlow DL, Stone MH, Ingham E, Fisher J (2003) Cement particles
containing radio-opacifiers stimulate pro-osteolytic cytokine pro-
duction from a human monocytic cell line. J Bone Joint Surg (Br)
85(6):9005
56. Topoleski LD, Ducheyne P, Cuckler JM (1990) A fractographic anal-
ysis of in vivo poly(methyl methacrylate) bone cement failure
mechanisms. J Biomed Mater Res 24(2):13554
57. Vale FM, Castro M, Monteriro J, Couto FS, Pinto R, Toscano G, Rico
JM (1997) Acrylic bone cement induces the production of free radi-
cls by cultured human fibroblasts. Biomaterials 18:11335
58. Verdonschot N (1995) Biomechanical failure scenarios for cement-
ed total hip replacement. Thesis
59. Verdonschot N, Huiskes R (1997) The effects of cement-stem
debonding in THA on the long-term failure probability of cement. J
Biomech 30(8):795802
60. Walker PS, Mai SF, Cobb AG, Bentley G, Hua J (1995) Prediction of
clinical outcome of THR from migration measurements on stan-
dard radiographs. A study of cemented Charnley and Stanmore
femoral stems. J Bone Joint Surg (Br) 77(5):70514
61. Wang JS, Aspenberg P, Goodman S, Lidgren L (1998) Interface
porosity in cemented implants in vitro study. 8th European Ortho-
peic society Meeting in Armsterdam, The Netherlands, May P, 2
62. Wang JS, Franzn H, Jonsson E, Lidgren L (1993) Porosity of bone
cement reduced by mixing and collecting under vacuum. Acta
Orthop Scand 64(2):14346.
63. Wang JS, Franzn H, Lidgren L (1999) Interface gap implantation
of a cemented femoral stem in pigs. Acta Orthop Scand 70(3):229
33.
64. Wang JS, Goodman S, Franzn H, Aspenberg P, Lidgren L (1994)
The effects of vacuum mixing on the microscopic homogenicity of
bone cement. Europ. J. Exper. Musculoskeletal Res 2:15965
65. Wang JS, Kjellson F (2001) Bone cement porosity in Vacuum Mixing
system. In: Walenkamp GHIM, Murray DW (eds) Bone cements and
Cementing technique. Springer, Berlin Heidelberg New York Tokyo,
pp 8195
66. Wang J-S, Toksvig-Larsen S, Mller-Wille P, Franzn H (1996) Is
their any difference between vacuum mixing systems in reducing
bone cement porosity? J Biomed Mater Res (Applied Biomaterials)
33:11519.
67. Wilkinson JM, Eveleigh R, Hamer AJ, Milne A, Miles AW, Stockely I
(2000) Effect of mixing technique on the properties of acrylic bone
cement. J Arthroplasty 15:6637
68. Wimhurst J, Brooks R, Rushton N (2001) The effects of particulate
bone cements at the bone-implant interface. J Bone Joint Surg (Br)
83(4):58892
69. Wixon RL, Lautenschlager EP, Novak MA (1987) Vacuum mixing of
acrylic bone cement. J Arthroplasty 2:14149
70. Yau WP, Ng TP, Chiu KY, Poon KC, Ho WY, Luk DK (2001) The perfor-
mance of three vacuum mixing cement guns- acomparison of the
fatigue properties of Simplex P cement. International Orthopaedics
25:290293