Scanning electron microscopy investigation of PMMA removal by laser irradiation (Er:YAG) in comparison with an ultrasonic system and curettage in hip joint revision arthroplasty


The cement often left in the femur socket during hip joint revision arthroplasty is usually removed by curettage. Another method for removing the cement is to use an ultrasonic system, and yet another alternative may be to use a laser system. The aim of these investigations was to determine the pulse rate and pulse energy of the Er:YAG laser for sufficient cement ablation. We also compared the results obtained using the laser with those obtained using an ultrasonic device or curettage by histological and scanning electron microscopy (SEM) investigation of the border zone between the polymethyl methacrylate (PMMA) and unfixed specimens of femoral bone. Therefore we prepared 30 unfixed human femur stems after hip joint replacement and prepared ten sagittal sections from each femur stem (in total 300 sections). Of these 300 specimens, 180 were treated with the Er:YAG laser, 60 with the ultrasonic system and 60 by curettage. The high pulse energy of 500 mJ and a pulse rate of 4 Hz provided the highest PMMA ablation rate, although the boundary surface between PMMA and femoral bone was not as fine-grained as found in samples treated at 15 Hz and 250 mJ. However, the treatment time for the same cement ablation rate with the latter settings was twice that at 4 Hz and 500 mJ. Compared to the boundary surfaces treated with the ultrasonic device or curettage, the laser-treated samples had a more distinct undifferentiated boundary surface between PMMA and femoral bone. After development of the Er:YAG-laser to provide higher pulse energies, it may in the future be an additional efficient method for the removal of PMMA in revision arthroplasty. The Er:YAG laser should be combined with an endoscopic and a rinsing suction system so that PMMA can be removed from the femoral shaft under direct vision.

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  1. 1.

    Lucht U (2000) The Danish hip arthroplasty register. Acta Orthop Scand 71:433–439

    CAS  PubMed  Article  Google Scholar 

  2. 2.

    Britton AR, Murray DW, Bulstrode CJ, McPherson K, Denham RA (1996) Long-term comparison of Charnley and Stanmore design total hip replacements. J Bone Joint Surg Br 78:802–808

    CAS  PubMed  Google Scholar 

  3. 3.

    Kavanagh BF, Ilstrup DM, Fitzgerald RH Jr (1985) Revision total hip arthroplasty. J Bone Joint Surg Am 67:517–526

    CAS  PubMed  Google Scholar 

  4. 4.

    Gray FB (1992) Total hip revision arthroplasty. Prosthesis and cement removal techniques. Orthop Clin North Am 23:313–319

    CAS  PubMed  Google Scholar 

  5. 5.

    Caillouette JT, Gorab RS, Klapper RC, Anzel SH (1991) Revision arthroplasty facilitated by ultrasonic tool cement removal. Part I: In vitro evaluation. Orthop Rev 20:353–357

    CAS  PubMed  Google Scholar 

  6. 6.

    Caillouette JT, Gorab RS, Klapper RC, Anzel SH (1991) Revision arthroplasty facilitated by ultrasonic tool cement removal. Part II: Histologic analysis of endosteal bone after cement removal. Orthop Rev 20:435–440

    CAS  PubMed  Google Scholar 

  7. 7.

    Weber U, Nietert M, Jacob E (1981) Ultrasonic treatment of bone cements. Z Orthop 119(3):234–243

    Article  CAS  PubMed  Google Scholar 

  8. 8.

    Brooks AT, Nelson CL, Hofmann OE (1995) Minimal femoral thickness necessary to prevent perforation by ultrasonic tools in joint revision surgery. J Arthroplasty 10(3):359–362

    Article  CAS  PubMed  Google Scholar 

  9. 9.

    Gardiner R, Hozack WJ, Nelson C (1993) Revision total hip arthroplasty using ultrasonically driven tools. A clinical evaluation. J Arthroplasty 8(5):517–521

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Honnart F (1996) Use of ultrasound for the removal of cement in hip prosthesis reoperations. Rev Chir Orthop Reparatrice Appar Mot 82(2):171–174

    CAS  PubMed  Google Scholar 

  11. 11.

    Karpman RR, Magee FP, Gruen TW (1987) The lithotriptor and its potential use in the revision of total hip arthroplasty. Orthop Rev 16(1):38–42

    CAS  PubMed  Google Scholar 

  12. 12.

    May TC, Krause WR, Preslar AJ (1990) Use of high energy shock waves for bone cement removal. J Arthroplasty 5(1):19–27

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Buchelt M, Kutschera HP (1993) Ablation of polymethylmethacrylate by Ho:YAG, Nd:YAG and Er:YAG lasers. Lasers Surg Med 13(6):638–646

    Article  CAS  PubMed  Google Scholar 

  14. 14.

    Choy DS, Kaminow IP, Kaplan M. Experimental Nd:YAG laser disintegration of methylmethacrylate. Analysis of gaseous products. Clin Orthop Relat Res (215):287–288

  15. 15.

    Mommsen J, Tönshoff HK (1993) Investigation and reduction of endangering by emissions during laser ablation of PMMA. Interim report of the Eureka Project, EU 643, 21/01/1993

  16. 16.

    Nelson JS, Yow L, Liaw LH, Macleay L, Zavar RB, Orenstein A, Wright WH, Andrews JJ, Berns MW (1988) Ablation of bone and methacrylate by a prototype mid-infrared erbium:YAG laser. Lasers Surg Med 8(5):494–500

    Article  CAS  Google Scholar 

  17. 17.

    Klanke J, Siebert WE, Scholz C, Dinkelaker F (1991) Histologic and scanning electron microscopic changes on cartilaginous surfaces after treatment with different lasers compared to mechanical tools. In: Siebert WE, Wirth CJ (eds) Laser in orthopedics. Thieme, Stuttgart, pp 129–135

    Google Scholar 

  18. 18.

    Scholz C, Matthes M, Kar H, Boenick U (1991) Removal of bone cement with laser. Biomed Tech (Berl) 36(5):120–128

    Article  CAS  Google Scholar 

  19. 19.

    Sherk HH, Lane G, Rhodes A, Black J (1995) Carbon dioxide laser removal of polymethylmethacrylate. Clin Orthop Relat Res (310):67–71

  20. 20.

    Scholz C, Matthes M, Kar H, Boenick U (1991) Möglichkeiten und Grenzen der Knochenzemententfernung mit dem Laser. Angewandte Lasermedizin; Fortschritte in der Orthopädie 10:1–14

  21. 21.

    Sherk HH, Kollmer C (1990) Revision arthroplasty using a CO2 laser. In: Sherk HH (ed) Lasers in orthopaedics. JB Lippincott, Philadelphia, pp 75–103

    Google Scholar 

  22. 22.

    Inglis R, Hermanni A, Windolf J, Pannike A (1990) Schonende. PMMA-Entfernung aus dem Femur mit dem CO2-Laser. Firmenmitteilung der Fa. Heraeus Instruments, Hanau, Germany

  23. 23.

    Meyer DR, Scholz C, Klanke J, Büchle A, Grothues-Spork M (1990) Der kurz gepulste CO2-Laser mit 9, 6 μm Wellenlänge im Vergleich zum Er:YAG-Laser bei der Laserosteotomie. Lasers Med Surg 6:150–155

    Google Scholar 

  24. 24.

    Biyikli S, Modest MF, Tarr R (1986) Measurements of thermal properties for human femora. J Biomed Mater Res 20:1335–1345

    Article  CAS  PubMed  Google Scholar 

  25. 25.

    Stuehmer KG (1987) The technique for cement extraction in revision hip arthroplasty. Akt Probl Chirurg Orthop 31:342–346

  26. 26.

    Walsh JT Jr, Flotte TJ, Deutsch TF (1989) Er:YAG laser ablation of tissue: effect of pulse duration and tissue type on thermal damage. Lasers Surg Med 9:314–326

    Article  PubMed  Google Scholar 

  27. 27.

    Davis GM, Gower MC (1987) Time resolved transmission studies of PMMA films during UV laser ablative photodecomposition. J Appl Phys 61:2090–2092

    Article  CAS  Google Scholar 

  28. 28.

    Garrison BJ, Srinivasan R (1985) Laser ablation of organic polymers: microscopic models for photochemical and thermal processes. J Appl Phys 57:2909–2914

    Article  CAS  Google Scholar 

  29. 29.

    Hibst R (1992) Mechanical effects of erbium-YAG laser bone ablation. Lasers Surg Med 12:125–130

    Article  CAS  PubMed  Google Scholar 

  30. 30.

    Yoshino T, Aoki A, Oda S, Takasaki AA, Mizutani K, Sasaki KM, Kinoshita A, Watanabe H, Ishikawa I, Izumi Y (2009) Long-term histologic analysis of bone tissue alteration and healing following Er:YAG laser irradiation compared to electrosurgery. J Periodontol 80(1):82–92

    Article  PubMed  Google Scholar 

  31. 31.

    Blaya DS, Guimaraes MB, Pozza DH, Weber JB, de Oliveira MG (2008) Histologic study of the effect of laser therapy on bone repair. J Contemp Dent Pract 9(6):41–48

    PubMed  Google Scholar 

  32. 32.

    Booth RE, Gordon SL Jr, Carney MD (1987) Use of the CO2 laser in revision hip surgery. Contemp Orthop 15:17–22

    Google Scholar 

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Correspondence to Klaus Birnbaum.

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Birnbaum, K., Gutknecht, N. Scanning electron microscopy investigation of PMMA removal by laser irradiation (Er:YAG) in comparison with an ultrasonic system and curettage in hip joint revision arthroplasty. Lasers Med Sci 25, 595–603 (2010).

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  • Endoprosthesis
  • Erbium:YAG laser
  • Laser
  • Polymethyl methacrylate
  • Ultrasonic extraction system
  • Scanning electron microscopy