Femoral preparation in cemented total hip arthroplasty: reaming or broaching?

Surgical techniques continue to be refined to improve the results of primary cemented total hip arthroplasty. Although there has been much research in the areas of cementation and implant design, little work has specifically addressed how bone preparation can be optimized on the femoral side. On the basis of available scientific data, it appears that the broach-only system has several potential advantages over the traditional ream-and-broach technique. Broaching is usually faster, leaves behind more bone stock, and may improve both microinterlock and macrointerlock. Additionally, the excess bone resulting from broaching without reaming does not seem to compromise fixation at the bone-cement interface. Such differences may become even more important as the indications for cemented hip arthroplasty broaden to include increasingly younger and more active patients, because revision in these individuals is likely. In most cases, reaming is probably counterproductive, although it may be advantageous when used to open the femoral canal, to prevent varus stem orientation, and to manage sclerosis or deformity of bone due to a preexisting hip disorder or the presence of internal fixation devices. Regardless of which method is chosen, good bone surface cleansing and cement penetration remain paramount. More studies comparing reamed and nonreamed preparation are necessary to resolve this controversial issue definitively.