CE ONLINE

Principles of Bone
Cement and the Process
of Bone Cement Mixing

An Online Continuing Education Activity

Sponsored By

Grant funds provided by

Welcome to

Principles of Bone
Cement and the Process
of Bone Cement Mixing
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS

This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own learning
needs and objectives. At the end of the activity, you will be assessed on the
attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas that
reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to reread the question and answer choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits

and provide verification, if necessary, for 7 years. Requests for certificates must
be submitted in writing by the learner.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

2014
All rights reserved
Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014
www.pfiedlerenterprises.com
Phone: 720-748-6144 Fax: 720-748-6196

Overview

For the past 50 years, polymethylmethacrylate (PMMA) bone cements have been widely used
as the anchoring/grouting agent in total joint replacements of the hip, knee, ankle, elbow, and
shoulder. Good quality cement is essential for long-term implant survival and the role of the
perioperative nurse in preparing that cement is vitally important. Strict adherence to good
cement mixing and application techniques is a key factor in reducing the rate of loosening
and also in increasing the long-term survival of the prosthesis. The purpose of this continuing
education activity is to provide a review of key concepts regarding composition, properties,
and types of bone cements and factors that affect bone cement polymerization. The evolution
of mixing and application techniques also will be described. The activity concludes with a
discussion of potential hazards posed by bone cement and safety considerations for patients
and members of the surgical team.

OBJECTIVES

After completing this continuing nursing education activity, the participant should be able to:
1. Review the components of bone cement.
2. Describe the types of bone cement available today.
3. Outline the history of bone cement mixing systems.
4. Differentiate the various bone cement mixing systems and application techniques.
5. Identify the safety issues related to the use of bone cement in the perioperative
practice setting.

INTENDED AUDIENCE

This continuing education activity is intended for perioperative registered nurses who are
interested in learning more about bone cement and the process of bone cement mixing.

CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing,
Provider Number CEP14944, for 2.0 contact hour(s).
Obtaining full credit for this offering depends upon completion, regardless of circumstances,
from beginning to end. Licensees must provide their license numbers for record keeping
purposes.
The certificate of course completion issued at the conclusion of this course must be
retained in the participants records for at least four (4) years as proof of attendance.
IAHCSMM
The International Association of Healthcare Central Service Materiel Management has
approved this educational offering for 2.0 contact hours to participants who successfully
complete this program.
3

IACET
Pfiedler Enterprises has been accredited as an Authorized Provider by the International
Association for Continuing Education and Training (IACET).
CEU Statements
As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its
programs that qualify under the ANSI/IACET Standard.
Pfiedler Enterprises is authorized by IACET to offer 0.2 CEUs for this program.

RELEASE AND EXPIRATION DATE

This continuing education activity was planned and provided in accordance with
accreditation criteria. This material was originally produced in June 2014 and can
no longer be used after June 2016 without being updated; therefore, this continuing
education activity expires in June 2016.

DISCLAIMER

Accredited status as a provider refers only to continuing nursing education activities and
does not imply endorsement of any products.

SUPPORT

Grant funds for the development of this activity were provided by CardinalHealth

AUTHORS/PLANNING COMMITTEE/REVIEWER

Susan K. Purcell Littleton, CO

Medical Writer/Author
Julia A. Kneedler, RN, MS, EdD
Program Manager/Reviewer
Pfiedler Enterprises

Aurora, CO

Judith I. Pfister, RN, BSN, MBA

Program Manager/Planning Committee
Pfiedler Enterprises

Aurora, CO

DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR

THOSE IN A POSITION TO CONTROL CONTENT FOR THIS ACTIVITY
Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest
for individuals who control content for an educational activity. Information listed below is
provided to the learner, so that a determination can be made if identified external interests
or influences pose a potential bias of content, recommendations or conclusions. The intent
is full disclosure of those in a position to control content, with a goal of objectivity, balance
and scientific rigor in the activity.
Disclosure includes relevant financial relationships with commercial interests related to
the subject matter that may be presented in this educational activity. Relevant financial
relationships are those in any amount, occurring within the past 12 months that create a
conflict of interest. A commercial interest is any entity producing, marketing, reselling,
or distributing health care goods or services consumed by, or used on, patients.
Activity Planning Committee/Authors/Reviewers:
Julia A. Kneedler, RN, MS, EdD
Co-owner of company that receives grant funds from commercial entities
Susan K. Purcell, MA
No conflict of interest.
Judith I. Pfister, RN, BSN, MBA
Co-owner of company that receives grant funds from commercial entities

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http://www.pfiedlerenterprises.com

INTRODUCTION

Polymethylmethacrylate (PMMA) bone cement is an essential component in many total

joint arthroplasty procedures. In a cemented arthroplasty, the main functions of the
cement are to immobilize the implant, transfer body weight and service loads from the
prosthesis to the bone, and increase the load-carrying capacity of the prosthesis-bone
cement-bone system. The term cement, however, is misleading since bone cement
acts more like a grout, filling in space in order to create a tight space to hold the implant
against bone. Good quality cement is essential for long-term implant survival and the role
of the perioperative nurse in preparing that cement is vitally important. Accurate bone
cement mixing and precise application techniques are critical to ensuring the stability and
longevity of the prosthesis. Since bone cement is prepared and used in the operating
room (OR) environment, it is important that all perioperative personnel recognize the
unique safety considerations that are related to its preparation and its use.

COMPONENTS OF BONE CEMENT

PMMA bone cements are usually supplied as two-component systems made up of a

powder and a liquid. These two components are mixed at an approximate ratio of 2:1 to
start a chemical reaction called polymerization, which forms the polymethylmethacrylate
(PMMA) cement.
Powder components1:
Copolymers beads based on the substance polymethylmethacrylate (PMMA);
Initiator, such as benzoyl peroxide (BPO), which encourages the polymer and
monomer to polymerize at room temperature;
Contrast agents such as zirconium dioxide (ZrO2) or barium sulphate (BaSO4)
to make the bone cements radiopaque; and
Antibiotics (eg, gentamicin, tobramycin).
Liquid components2:
A monomer, methylmethacrylate (MMA);
Accelerator (N,N-Dimethyl para-toluidine) (DMPT);
Stabilizers (or inhibitors) to prevent premature polymerization from exposure to
light or high temperature during storage; and
Chlorophyll or artificial pigment; sometimes added to cements for easier
visualization in case of revision.
There is a difference between PMMA bone cement and PMMA; however, many
healthcare personnel use the terms interchangeably and PMMA has become shorthand
for bone cement. However, PMMA is the substance from which copolymers are
derived for the powder component. When the copolymer powder is mixed with the MMA
monomer liquid, polymerization occurs and PMMA bone cement is created.

POLYMERIZATION

Polymerization is a chemical reaction in which two or more small molecules combine to

form larger molecules that contain repeating structural units of the original molecules. In
the case of bone cement, the polymerization process starts when the copolymer powder
and monomer liquid meet, reacting together to produce an initiation reaction creating free
radicals that cause the polymerization of the monomer molecules. The original polymer
beads of the powder are bonded into a dough-like mass, which eventually hardens into
hard cement.
The polymerization process is an exothermic reaction, which means it produces
heat. With a maximum in vivo temperature of 40C to 47C, this thermal energy is
dissipated into the circulating blood, the prosthesis, and the surrounding tissue. Once
polymerization ends, the temperature decreases and the cement starts to shrink.
Phases and Times
The polymerization process can be divided into four different phases: mixing, waiting,
working, and setting. Package inserts that come with the products often refer to Dough
Time, Working Time, and Setting Time. Dough Time and Setting Time are measured from
the beginning of mixing; Working Time is the interval between Dough Time and Setting
Time. Both the Phases and corresponding Times are described below.
Mixing Phase
The mixing phase represents the time taken to fully integrate the powder and liquid. As
the monomer starts to dissolve the polymer powder, the benzoyl peroxide is released into
the mixture. This release of the initiator benzoyl peroxide and the accelerator DMPT is
actually what causes the cement to begin the polymerization process. It is important for
the cement to be mixed homogeneously, thus minimizing the number of pores.
Waiting Phase/Dough Time
During this phase, typically lasting several minutes, the cement achieves a suitable
viscosity for handling (ie, can be handled without sticking to gloves). The cement is a
sticky dough for most of this phase.
Dough time is the time point measured from the beginning of mixing to the point when
the cement no longer sticks to surgical gloves. Under typical conditions (23C-25C,
65% relative humidity), dough time is 2-3 minutes after beginning of mixing for most bone
cements. Before this time point, after the components are well mixed, the bone cement
may be loaded into a syringe, cartridge, or injection gun for assisted application.3
Working Phase/Working Time
The working phase is the period during which the cement can be manipulated and the
prosthesis can be inserted. The working phase results in an increase in viscosity and the
generation of heat from the cement. The implant must be implanted before the end of the
working phase.

Working time is the interval between the dough and setting times, typically 5-8 minutes.
Previously, this represented the full time interval available for use of a particular mix of
bone cement. The use of mechanical introduction tools, such as syringes and cartridges,
extends this time by 1 to 1.5 min.4
Setting Phase/Setting Time
During this phase, the cement hardens (cures) and sets completely, and the temperature
reaches its peak. The cement continues to undergo both volumetric and thermal
shrinkage as it cools to body temperature. Hardening is influenced by the cement
temperature, the OR temperature, and the body temperature of the patient.
Setting time is the time point measured from the beginning of mixing until the time at
which the exothermic reaction heats the cement to a temperature that is exactly halfway
between the ambient and maximum temperature (ie, 50% of its maximum value), usually
about 8-10 minutes. The temperature increase is due to conversion of chemical to
thermal energy as polymerization takes place.5
Factors that Affect Dough, Working, and Setting Times
Factors that affect dough, working, and setting times include the following6:
Mixing Process Mixing that is too rapid can accelerate dough time and is not
desirable since it may produce a weaker, more porous bone cement.
Ambient Temperature Increased temperature reduces both dough and setting
times approximately 5% per degree Centigrade, whereas decreased temperature
increases them at essentially the same rate.
Humidity High humidity accelerates setting time whereas low humidity retards
it.
The combination of these factors is such that in a cold operating room on a very dry
winter day, setting time may stretch out and raise concerns as to whether there is
something wrong with the bone cement kit in use. There usually is not, but patience is
required under these conditions. Water (or anything else) should never be added to bone
cement in an attempt to modify its curing behavior.
Why Dont All Cements Behave the Same?
Despite the fact that basic PMMA bone cement materials are the same, the behavior of
various cement products can be significantly different when they are mixed under similar
conditions. There are several reasons for these differences:
The polymer component of a number of cements is not purely PMMA. Some
cement may contain PMMA copolymers such as methyl acrylate and styrene in
the powder and additional polymers such as butyl methacrylate. All cements are
labelled to show their ingredients.
The ratio of the components and the overall powder-to-liquid ratio may differ
between cements.

 The size, shape and weight of the polymer molecules can vary considerably.
Manufacturing processes may differ.
Sterilisation method may differ (eg, gamma, and ethylene oxide gas sterilisation).

CEMENT PROPERTIES

Cement properties critical for operating procedures, such as viscosity change, setting
time, cement temperature, mechanical strength, shrinkage, and residual monomer, are
determined during polymerization. These properties will influence cement handling,
penetration, and interaction with the prosthesis. The most important properties are
discussed below.
Cement Porosity
Porosity is the fraction of the volume of an apparent solid that is actually empty space.
High bone cement porosity compromises the cements mechanical strength and
decreases its fatigue life. This may lead to aseptic loosening. Sources of porosity in
cured bone cement include:
Trapped air between the powder beads as the powder is wetted.
Trapped air in the cement during mixing.
Trapped air in the cement during transfer from mixing container to application
device.
Hand mixing bone cement in an open bowl may introduce the greatest possibility of
these occurrences, which is why hand-mixed cement can contain a substantial number of
pores. Centrifugation and vacuum mixing methods, and pressurized cement application
can decrease the porosity of bone cement.
Cement Viscosity
Viscosity is a measure of the resistance of a fluid to deformation under shear forces and
is commonly described as thickness of a fluid. Viscosity also represents the resistance
to flow and is thought to be a measure of fluid friction. Cement viscosity determines the
handling and working properties of the cement.
Mixing together the powder and the liquid components marks the start of the
polymerization process. During the reaction, the cement viscosity increases, slowly at
first, then later more rapidly. During the working phase, there are two requirements for
bone cement viscosity it must be sufficiently low to facilitate the delivery of the cement
dough to the bone site, and it must penetrate into the interstices of the bone.7 On the
other hand, the viscosity of the bone cement should be sufficiently high to withstand
the back-bleeding pressure, thus avoiding the risk of inclusion of blood into the cement
because this could significantly reduce the stability of the bone cement. It is important
that the cement retains an optimized viscosity for an adequate duration to allow a
comfortable working time.8

10

Viscosity affects the following9:

Mixing behaviour;
Penetration into cancellous bone;
Resistance against bleeding; and
Insertion of the prosthesis.
Cement Temperature
To achieve optimal cement properties, it is important to adhere to the time schedules
indicating the correlation of temperature to handling time. These time schedules are
usually included in the manufacturers instructions for the bone cement.
Effects of Temperature:
Temperature affects mixing time, delivery of the cement, prosthesis insertion, and
other aspects of the cementing process.
Storage temperature will affect the cement times not just the temperature at
which it is mixed.
If cement has been stored in a cold environment, all the phases apart from the
mixing phase will be prolonged. High-viscosity cements are sometimes pre-chilled
for use with mixing systems for easier mixing and prolonged working phase. This
will also increase the setting time.
If cement has been stored in a warmer environment, all phases will be shorter.
Issues created by high temperatures:
Integration of the powder and liquid can be difficult.
Extrusion from a delivery gun can become difficult and may reduce delivery
pressures.
Potential exists for cement to be inserted during the setting phase.
Laminations can form between 3.5 and 6.5 minutes and reduce cement
strength by up to 54%.10
Mechanical Properties
The aim of a good cement mix is to produce bone cement that has the best mechanical
properties possible so that it can carry out its load transfer role successfully over the
lifetime of the implant. Once positioned within the hip or knee replacement, the cement
around the prosthesis is subjected to a series of physical forces that will have an effect
on the lifespan of the cement. These physical forces subject the cement to fatigue, creep,
and high stresses. The mechanical properties of the cement (eg, resistance to fatigue
and creep, and strength) should be enhanced as much as possible.

11

Fatigue
Fatigue is the failure of a component after it is subjected to a large number of alternating,
fluctuating loads; fatigue strength is a measure of a bone cements durability. If applied
only once, these loads would not be large enough to cause failure. A good example of
this is a paper clip, which when bent once will not break, but after it has been bent a
number of times, it will break easily.
As the cemented implant is subjected to not only static load but also dynamically
alternating loads, the fatigue properties of the cement affect survival of the implant.
Cement will have a natural lifespan and the repeated loads it is subjected to will, over
time, cause it to break down and fail. It is the quality of the cement mix that will determine
its lifespan. A well-mixed cement will be better equipped to deal with the loads placed
upon it.
The ability of bone cement to resist fatigue is critical given the loads to which it will be
subjected. Clinical evidence has documented the existence of fatigue cracks in revisionretrieved cement11,12 and in postmortem retrieved stem/cement/bone constructs.13 This
suggests that the fatigue resistance of bone cement should be optimized to prevent
fatigue failure.
Creep
Creep is the deformation of a material under constant load. Under constant load, a
material capable of creep will deform by an amount dependent on the size of the load
and the length of time it is applied. Creep generally increases with temperature. Creep
essentially is a mechanical problem that slowly and steadily can erode the long-term
performance of an implant. Cements with higher porosity are less resistant to creep
deformation.
Polymers are particularly susceptible to creep because of their molecular structure.
Therefore, bone cement, as a polymer, is likely to exhibit creep as it is under a load and
is at 37C in the body.
Significant bone cement creep will lead to implant subsidence, which, in turn, may lead to
failure.14 In the 1990s, a new formulation of bone cement had to be withdrawn after it was
found to significantly creep, leading to implant subsidence, aseptic loosening, and high
revision rates.15,16
Interestingly, a small degree of creep may in fact be advantageous in the early
postoperative stages with some implant designs. A polished, tapered stem without a
collar relies on some subsidence so that it becomes wedged in the bone cement,
thereby improving the load transfer mechanism.17
Stress
Stress is the load applied to a material over a given area. Stresses in the hip joint
are a combination of compression, bending, and torsional (twisting) forces. As load is
transferred during walking, the new joint and cement will be subjected to high stresses.
If these high stresses exceed the strength of the cement, it will deform permanently and
then, possibly, fail.
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TYPES OF BONE CEMENT

Cements can be grouped as high, medium, or low viscosity, with or without antibiotics.
The viscosity designation refers to the viscosity of the powder and liquid during the
mixing phase: high-viscosity cement is dough-like, while low-viscosity cement is more
like a liquid. The handling phases of different viscosity cements also vary considerably
and the choice of which cement to use is often surgeon preference. For example, a 2006
national survey of 587 surgeons in the UK found that high-viscosity cement was used
in total hip arthroplasty by 82% of the surgeons, medium-viscosity cement by 12%, and
low-viscosity cement was used by 6%.18
High Viscosity
High-viscosity bone cements have a short mixing phase and lose their stickiness quickly.
This makes for a longer working phase. The viscosity remains constant until the end of
the working phase. The setting phase lasts between one minute 30 seconds and two
minutes.19 High-viscosity cements are associated with reduced revision rates for total hip
arthroplasty.20
Medium Viscosity
These cements typically have a long waiting phase of three minutes, but during the
working phase, the viscosity only increases slowly. Setting takes between one minute 30
seconds, and two minutes 30 seconds.21
Low Viscosity
Low-viscosity cements have a long waiting phase of three minutes and the viscosity
rapidly increases during the working phase, making for a short working phase. As
a consequence, application of low-viscosity cements requires strict adherence to
application times. The setting phase is one to two minutes long.22
Antibiotic Cements
Periprosthetic infection is the most feared complication in total hip and knee replacement.
The infection usually leads to a complete failure of the joint replacement, resulting in
a long series of operative procedures, great discomfort for the patient, and significant
costs.
The use of antibiotic-impregnated bone cement to treat musculoskeletal infection has
been reported in the literature for more than three decades despite the fact that it wasnt
until 2003 that the first pre-blended bone cement containing an antibiotic (tobramycin)
became available for sale in the United States, specifically for the treatment and
reimplantation of infected arthroplasties.23,24 Prior to 2003, U.S. surgeons prepared
antibiotic cement on-site (ie, in the operating room) by adding antibiotic powder to the
powdered bone cement prior to the addition of the liquid monomer. In Europe, however,
pre-blended antibiotic bone cements have been available since the 1970s and the
indications and scientific evidence for its use have expanded to primary arthroplasty
to minimize postoperative infection. Use of antibiotic cements for primary arthroplasty,

13

however, remains controversial in the United States. The primary arguments proffered
against the routine use of antibiotic bone cement are lack of efficacy, adverse effects on
mechanical properties, increased costs, bacterial resistance, and systemic toxicity.25,26
However, there is significant evidence to refute these arguments.27,28,29
The elution of antibiotics from PMMA bone cement can be affected by certain factors
including the type of cement used, preparation methods, surface characteristics, porosity
of the cement, and the amount and/or type of antibiotics used.30
Not all antibiotics are suitable for use in bone cements. The following bacteriologic and
physical and chemical factors should be considered in the choice of an antibiotic31:
Preparation must be thermally stable and able to withstand the exothermic
temperature of polymerization.
Must have broad antimicrobial coverage.
Must be available as a powder.
Must have a low incidence of allergy.
Must not significantly compromise mechanical integrity.
Must elute from the cement over an appropriate period of time.
Gentamicin and tobramycin are the only antibiotics available in U.S. commercial antibiotic
bone cement products; tobramycin is the most often used and studied antibiotic added
to cement worldwide, but gentamicin is more common in the United States.32 Other
antibiotics (singly or in combination with other antibiotics) that have been studied include
vancomycin, cephalothin, clindamycin, meropenem, teicoplanin, ceftazidime, imipenem,
piperacillin, and ciprofloxacin.33,34,35

HISTORY OF BONE CEMENT MIXING SYSTEMS

Manual Mixing
Until the 1980s, the composition and preparation of bone cement did not stray much from
the standards introduced in 1959 by Sir John Charnley, a British orthopaedic surgeon
who pioneered the hip replacement operation.36 Techniques for improving cement
strength were not extensively tried.
Original mixing techniques were either hand- or bag-mixing. The liquid was injected into
a powder bag and the two components were mixed by kneading. As mixing techniques
evolved, an open bowl was used to mix the cement. The liquid and powder were poured
into a plastic or stainless steel bowl and then mixed together with a spatula. A 1988
study by Linden of 46 samples of acrylic cement mixed by seven nurses found that a
manual mixing technique lacks reproducibility and produces cements with uncontrollable
porosity.37
Early in the use of open bowl mixing, exposure to the resulting noxious fumes created
serious safety concerns. A certain amount of porosity in the final material remains
unavoidable with conventional hand mixing techniques today, due to the air introduced
14

by stirring during hand spatulation. In order to reduce both the harmful fumes as well as
the introduction of air into the cement mixture, the closed bowl technique, using a paddle
mixing system and wall suction to evacuate the fumes, was developed.
Vibration
During the 1980s, a vibrating mixing technique was introduced in hopes of improving
bone cement properties. The results, however, were not convincing.38
Centrifugation
In this technique, cement was first mixed manually and then subjected to centrifugation
to eliminate any air inclusions introduced during mixing and thus reduce porosity in
hopes of improving compressing strength and handling properties. The technique
required chilling the liquid monomer prior to mixing in order to negate the shortening
effect of centrifugation on setting time. The resulting low-viscosity mixture then was
introduced into a cement syringe, which was centrifuged at high speed for a short period
of time. The method succeeded in reducing porosity but procedures varied significantly
depending on the type of centrifugation and cement used.
Vacuum Mixing
Also in the 1980s, mixing under vacuum was introduced to reduce exposure to fumes
while also improving tensile strength and fatigue life of bone cement.39,40,41,42 After some
refining, it produced better results than centrifugation, which was soon thereafter retired
in favor of vacuum mixing43 and quickly became the preferred method of mixing. For
example, a 2006 national survey of 587 surgeons in the UK found that 94% were using
vacuum mixing systems for bone cement preparation with total hip arthroplasty.44
In most operating rooms today, bone cement is mixed under a vacuum, which results in a
low porosity cement with increased strength and resistance to cement fatigue and creep.
Trying to eliminate all of the porosity by using a very high vacuum level can promote
excessive shrinkage and cracking.
With a vacuum mixing system, the cement is mixed in a syringe, bowl, or cartridge. All of
these systems consist of an enclosed chamber connected to a vacuum source (eg, wall
suction or a dedicated vacuum pump). All ingredients are added and mixed while the
system is closed.
The methods for application of bone cement include hand packing, injection, and gun
pressurization.
Hand packing The original method for hip arthroplasty was hand packing,
where cement in the femoral canal was finger packed. The proximal end was
packed with cement by pressing with the fingers or thumbs; this pressurization
forced the cement into the bone interstices. Cementing in total knee arthroplasty
is still commonly hand-packed because the surfaces are readily visualized, which
makes the application with pressure by hand feasible.
Injection Syringes are used to apply, or inject, the cement.

15

 Gun pressurization Injection of the cement with a gun offers a mechanical

advantage that allows the surgeon to force more cement into the interstices of
the bone via higher pressurization. The pressurization tips of these devices allow
more cement to be forced tightly into the bone while also preventing overflow.

SAFETY ISSUES RELATED TO BONE CEMENT

The components of PMMA bone cement (powder and liquid MMA monomer) are toxic
and highly flammable. As a consequence, perioperative personnel must be aware of the
potential hazards for both personnel and patients in the OR environment. Appropriate
safety precautions must be implemented to reduce the risk of exposure and to monitor
patient reactions closely. The specific hazards associated with the use of PMMA bone
cement are described below.
Flammability/Combustion Hazards
As packaged, the product is considered stable. Nevertheless, the powder component
is combustible and sensitive to static discharge. The liquid component is a volatile
flammable liquid that slowly attacks rubber. The liquid will polymerize very readily and all
contamination must be avoided, particularly organic peroxides, catalysts, free radicals
generators and multivalent metal oxides, especially when wet. Heat and strong light,
particularly fluorescent or UV, could cause polymerization.45 The operating room should
be adequately ventilated to eliminate monomer vapors. Ignition of monomer vapors
caused by the use of electrocautery devices in surgical sites near freshly implanted bone
cement has been reported.46
Health Risks to Personnel47
Caution should be exercised during the mixing of the liquid and powder components
of the PMMA bone cement to prevent excessive exposure to the concentrated vapors
of the liquid methylmethacrylate (MMA) monomer, which may produce irritation of the
respiratory tract, eyes, and possibly the liver. MMA fumes, which are emitted during
preparation of PMMA bone cement, have been shown to have toxic side effects ranging
from allergic reactions to neurological disorders. Although there is no evidence for
potential carcinogenicity of the substance, all efforts should be made to reduce the
exposure.48 The permissible exposure limit (PEL) value established by OSHA is a timeweighted average limit of 100 parts of MMA per million (ppm) of air or a time-weighted
average of 410 milligrams of MMA per cubic meter of air during any 8-hour work shift in a
40-hour work week.49
Skin contact with the liquid monomer can cause contact dermatitis and hypersensitivity
reactions. The MMA monomer is a powerful lipid solvent. It should not contact rubber or
latex gloves. Double gloving or use of special gloves resistant to the monomer, and strict
adherence to the mixing instructions may diminish the possibility of contact dermatitis
and hypersensitivity reactions. The mixed PMMA bone cement should not contact the
gloved hand until the cement has acquired the consistency of dough.

16

Eye contact with the liquid can be quite serious, causing considerable irritation or
burns to the eyes. Soft contact lenses are very permeable and should not be worn
where methylmethacrylate is being mixed because the lenses are subject to pitting and
penetration by the vapors. Personnel wearing soft contact lenses should not mix PMMA
bone cement or be nearby.
Health Risks to Patients
According to the U.S. Food and Drug Administration (FDA),
Serious adverse events, some with fatal outcome, associated with the use of the
PMMA bone cement include myocardial infarction, cardiac arrest, cerebrovascular
accident, and pulmonary embolism. The most frequent adverse reactions
are transitory decreased blood pressure, elevated serum gamma-glutamyltranspeptidase (GGTP) up to 10 days postoperation, thrombophlebitis, hemorrhage
and hematoma, pain and/or loss of function, loosening or displacement of the
prosthesis, superficial or deep wound infection, trochanteric bursitis, short-term
cardiac conduction irregularities, heterotopic new bone formation, and trochanteric
separation. Other potential adverse events associated with the use of PMMA
bone cement include allergic pyrexia, hematuria, dysuria, bladder fistula, delayed
sciatic nerve entrapment from extrusion of the bone cement beyond the region of
its intended application, local neuropathy, local vascular erosion and occlusion,
intestinal obstruction because of adhesions and stricture of the ileum from the heat
released during the exothermic polymerization.50
Hypotensive reactions can occur between 10 and 165 seconds after application of
the PMMA bone cement and can last for 30 seconds to 5 or more minutes. Some
hypotensive reactions have progressed to cardiac arrest. The blood pressure of patients
should be monitored carefully during and immediately following the application of the
PMMA bone cement. In addition, overpressurization of the PMMA bone cement should
be avoided during insertion of the PMMA bone cement and implant in order to minimize
the occurrence of pulmonary embolism.51
Bone cement implantation syndrome (BCIS) is a poorly dened, poorly understood,
rare, and potentially fatal intraoperative complication occurring in patients undergoing
cemented orthopaedic surgeries.52,53 It can occur within minutes of the procedure; it also
may be seen in the postoperative period in a milder form causing hypoxia and confusion.
BCIS has no agreed upon definition; it is characterized by a number of clinical features
that may include hypoxia, hypotension, cardiac arrhythmias, increased pulmonary
vascular resistance (PVR), and cardiac arrest. It is most commonly associated with,
but is not restricted to, hip arthroplasty. It usually occurs at one of the five stages in
the surgical procedure; femoral reaming, acetabular or femoral cement implantation,
insertion of the prosthesis, or joint reduction.54

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RECOMMENDED PRACTICES FOR SAFE USE OF PMMA BONE CEMENT

The Association of periOperative Registered Nurses (AORN) Recommended Practices for
a Safe Environment of Care states that the potential hazards associated with the use of
methylmethacrylate in the practice setting should be identified and safe practices should be
established. Safe practices include the following measures55:

Material safety data sheet (MSDS) information for methylmethacrylate must be

readily accessible to employees within the practice setting. This information includes
identification of hazards, precautions or special handling, signs and symptoms of
toxic exposure, and first aid treatments for exposure. Methylmethacrylate should be
handled according to its MSDS.
Methylmethacrylate fumes should be extracted from the environment; the fumes
should be exhausted to the outside air or absorbed through activated charcoal.
Vacuum mixers with fume extraction should be used to decrease the fume levels to
which users are exposed.
Eye protection should be worn to prevent contact with eyes. Methylmethacrylate
fumes may produce an adverse reaction with soft contact lenses, leading to irritation
and potentially, corneal ulceration. There is no documented evidence of problems
associated with hard contact lenses.
The manufacturers recommendations should be followed for mixing and the required
personal protective equipment (PPE).
A second pair of gloves should be worn when handling methylmethacrylate and should
be discarded after use. The manufacturers instructions should be followed regarding
the composition of the second pair of gloves. Methylmethacrylate may be absorbed
through the skin and may also penetrate many plastic and latex compounds, leading
to dermatitis. The liquid component of the cement should not come in contact with
gloves.
A cement gun or mixing system, instead of hand mixing, should be used to decrease
handling of the product. The cement mixture should not be touched until it is the
consistency of dough.
For methylmethacrylate spills:
The area of the spill should be ventilated until the odor has dissipated;
All sources of ignition should be removed;
Appropriate PPE should be worn during the clean-up;
The spill area should be isolated;
The liquid component should be covered with an activated charcoal absorbent; and
The waste product should be disposed of in a hazardous waste container.
Methylmethacrylate is a hazardous waste and should be disposed of according to
state, local, and federal regulations.

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SUMMARY

PMMA bone cement has been used in cemented arthroplasty procedures for over 50
years. Good quality cement is essential for long-term implant survival and the role of
the perioperative nurse in preparing that cement is vitally important. The quality of bone
cement is determined by several factors, including the type of cement selected, (ie,
viscosity, presence of antibiotics) and strict adherence to instructions provided by the
manufacturer. Its effectiveness is highly dependent upon the use of optimal mixing and
application techniques. The components of PMMA bone cement (powder and liquid MMA
monomer) are toxic and highly flammable. As a consequence, perioperative personnel
must be aware of the potential hazards for both personnel and patients in the OR
environment. Appropriate safety precautions must be implemented to reduce the risk of
exposure and to monitor patient reactions closely.

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GLOSSARY
Accelerator

A catalytic agent used to hasten a chemical

reaction.

Bone Cement Implantation

A rare complex of sudden physiologic changes
Syndrome (BCIS)
characterized by hypoxia, hypotension or both

and/or unexpected loss of consciousness

occurring around the time of cementation,

prosthesis insertion, reduction of the joint or,

occasionally, limb tourniquet deflation in a patient

undergoing cemented bone surgery. Symptoms

may occur within minutes of the use of PMMA
cement.
Compressive Strength

The measure of bone cements durability during

weight bearing.

Copolymer

A polymer derived from two or more monomers.

Creep

The measure of bone cements reaction to a

combination of compressive and shear forces that
occur during a variety of normal activities of daily
living over time.

Dough Time

The time point measured from the beginning of

mixing to the point when the cement no longer
sticks to surgical gloves.

Exothermic Reaction

A chemical reaction that produces heat.

Fatigue

The failure of a component after it is subjected to

a large number of alternating, fluctuating loads.

High-Viscosity Cements

Cements that have a short waiting/sticky phase

and a long working phase. The viscosity remains
constant until the end of the working phase.

Laminations

Faults or folds in the bone cement, which may be

caused by high temperature or intrusions such
as bone, water, blood, etc. Laminations create
potential areas of weakness in the cement mantle
where a failure can occur.

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Low-Viscosity Cements

Cements that have a long waiting phase of about

3 minutes; the viscosity rapidly increases during
the working phase, making for a short working
phase.

Medium-Viscosity Cements

Cements that have a long waiting phase of

approximately 3 minutes, but during the working
phase, the viscosity only increases slowly.

Methylmethacrylate (MMA)

The liquid component of bone cement; MMA is a

monomer.

Mixing Phase

The phase in which the monomer is thoroughly

mixed throughout the powder bed and
polymerization is initiated.

Monomer

A molecule of low molecular weight capable of

reacting with identical or different molecules of
low molecular weight to form a polymer. For bone
cement, the monomer MMA (a liquid) reacts with
the copolymers based on PMMA to form PMMA
bone cement.

Parts per Million (ppm)

Parts per million refers to a substance per

million parts of air; it is a measure of the
substances concentration of volume in air.

Permissible Exposure Limit (PEL) The permissible exposure limit of a hazardous

substance, which is enforceable by OSHA.
Polymerization

The formation of a compound, usually of high

molecular weight, by the combination of several
low molecular weight compounds (eg, monomers,
copolymers).

Polymethylmethacrylate (PMMA)

PMMA is a synthetic acrylic resin used as

the basis for PMMA bone cement. Bone
cement consists of two primary components:
a powder consisting of copolymers based on
polymethylmethacrylate (PMMA), and a liquid
monomer, methylmethacrylate (MMA).

21

Porosity

The presence of entrapped air in bone cement.

High bone cement porosity compromises the
cements mechanical strength and decreases its
fatigue life. Centrifugation and vacuum mixing
methods, and pressurized cement application can
decrease the porosity of bone cement.

Setting Phase

The final curing state of the polymerization

process of bone cement; the implant should
already be in its final position.

Setting Time

Time point from the beginning of mixing until the

time at which the exothermic reaction heats the
cement to a temperature that is exactly halfway
between the ambient and maximum temperature
(ie, 50% of its maximum value), usually about
8-10 minutes.

Stress

The load applied to a material over a given area.

Viscosity

A measure of the resistance of a fluid to

deformation under shear forces and is commonly
described as thickness of a fluid. The
viscosity of bone cement affects its handling
characteristics, handling time, and penetration of
the cement into the cancellous bone.

Waiting Phase

The phase of the polymerization process where

bone cement begins to swell and viscosity begins
to increase, creating a sticky dough. By the end
of the waiting phase, the doughy cement will not
stick to surgical gloves.

Working Phase

The time during the polymerization process at

which bone cement is ready for application; the
implant must be implanted before the end of the
working phase.

Working Time

The interval between the dough and setting times,

typically 5-8 minutes.

22

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Please click here for the

Post-Test and Evaluation

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