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barrack grading of cementing

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Barrack grading cementing total hip arthroplasty grades A B C D criteria

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Barrack Grading of Cement Mantle (Total Hip Arthroplasty)

The Barrack et al. (1992) grading system evaluates the quality of the femoral component cement mantle on postoperative radiographs. It was later modified by Mulroy et al. (1995). The system assesses radiolucency at the bone-cement interface.

Grades

GradeDescriptionRadiographic Finding
A"White out"Complete filling of the medullary canal - no radiolucencies. Best possible result.
BSlight radiolucencyRadiolucency at the bone-cement interface involving < 50% of the interface.
CSignificant radiolucencyLucency surrounding 50-99% of the interface, OR any cement mantle defect.
DWorstComplete lucency on any projection, OR a defect of the mantle at the stem tip.

Memory Aid

A B C D = Amazing, Bordering, Concerning, Deadly (loosening likely)

Clinical Significance

  • Grades A and B - acceptable cement mantles; associated with good long-term fixation
  • Grades C and D - associated with significantly increased risk of aseptic loosening (as reported by Malik et al. and Chambers et al.)
  • Mulroy et al. specifically noted that a cement mantle < 1 mm thick and defects in the mantle are associated with early loosening

Radiographic Examples (from Barrack et al., 1992)

Barrack grading - A shows "white out" complete fill, B shows slight radiolucency at the cement-bone interface
Fig: A = Grade A ("white out", excellent cement distribution). B = Grade B (slight radiolucencies at cement-bone interface).

Common Technical Failures Leading to Poor Grades (C/D)

  1. Inadequate distal cement plug - stem tip unsupported
  2. Removal of all trabecular bone, leaving no surface for cement intrusion
  3. Inadequate cement quantity or laminated bolus
  4. Failure to pressurize cement - poor penetration into interstices
  5. Stem motion during cement hardening
  6. Poor component alignment (not centralized in canal)
  7. Voids in cement due to poor mixing or injection technique
Source: Campbell's Operative Orthopaedics, 15th Ed. (2026), p. 325 | Original paper: Barrack RL, Mulroy RD, Harris WH. Improved cementing techniques and femoral component loosening - J Bone Joint Surg Br. 1992;74(3):385-389.
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