The cement in cement technique for revision total hip arthroplasty (THA) has shown good results in selected cases. However results of its use in the revision of hemiarthroplasty to THA has not been previously reported.
Between May 1994 and May 2007 28 (20 Thompson’s and 8 Exeter bipolar) hip hemiarthroplasties were revised to THA in 28 patients using the cement in cement technique. All had an Exeter stem inserted at the time of revision. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of hemiarthroplasty revision was 80 (35 to 93) years. The reason for revision was acetabular erosion in 12 (43%), recurrent dislocation in 8 (29%), aseptic loosening in 4 (14%), periprosthetic fracture in 2 (7%) and infection in 2 (7%) patients. No patient has been lost to follow up. 3 patients died within 3 months of surgery. The mean follow up of the remainder was 50 (16 to 119) months. Survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. 3 cases (11%) have since undergone further revision, 1 for recurrent dislocation, 1 for infection, and 1 for periprosthetic fracture. The cement in cement technique can be successfully applied to revision of hip hemiarthroplasty to THA. It has a number of advantages in this elderly population including minimizing bone loss, blood loss and operative time.
Survivorship of the standard Exeter Universal cemented stem with revision of the femoral component for aseptic loosening as the endpoint has been reported as 100% at 12 years. A version for use in smaller femora, the Exeter 35.5 mm stem, was introduced in 1988. Although also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem.
Between August 1988 and August 2003 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 (18 to 86) years with 73 patients under the age of 50 years. The diagnosis was osteoarthritis 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in 3, secondary to Perthes disease in 2 and avascular necrosis of the hip in 1 patient. The fate of every implant is known. At a median follow-up of 8 (5 to 19) years survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. 15 cases (7.8%) underwent further surgery – 11 for acetabular revision, 1 for stem fracture and 3 others. Although smaller than a standard Exeter Universal polished tapered cemented stem, with a shorter, slimmer taper, the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients.
This presentation introduces a new tool to be used in the cementing of acetabular components in total hip arthroplasty, the ‘Rim Cutter’. The Rim Cutter is designed to cut a ledge in the rim of the acetabulum into which a flanged cup can be cemented. The flange is trimmed such that it fits precisely into the ledge cut in the acetabulum. We present the in vitro pilot study of the effect of using this tool on the intra-acetabular cement mantle pressure during cup insertion and also the effect on the depth of cement penetration as the cup is inserted. A significant improvement in both cement pressure and cement penetration over conventional flanged and unflanged cups is noted. Improved cement penetration around the rim of the acetabulum in THR has implications for reducing the rate of aseptic loosening. The pilot study also suggests other beneficial features of using the rim cutter such as improved cup centralisation, control of orientation and the prevention of the cup ‘bottoming out’. Further in vivo studies are required to better assess its efficacy.
Vast amount of literature is available on mechanical properties of PMMA, but not about the composite specimens of old and new cement. This is important, as in cement revision has become established technique with good clinical results. Originally Greenwald and later Li described properties of such specimens. However in these studies the old samples were only few days old, unlike clinical situation, where the old cement is a few years old. We therefore decided to test short-term mechanical properties of composite specimens and compare these with new uniform specimens. We choose specimens of cement 3–17 years old (median 11.8) for the manufacturing of the composite specimens.
We evaluated short-term mechanical properties of composite specimens and compared these with new uniform specimens.
The average age at operation of the survivors was 55.7 years. No significant radiological subsidence between the cement and bone was found. Mean subsidence between the stem and the cement was 2.15mm, most occurring in the first 5 years and in all but 1 being less than 4. The maximum was 18mm (grade D cementing). Cementing grades were B in 65%, C in 27%, D in 8%. Resorption of the neck (13%) was associated with excessive socket wear or cement left over the cut surface of the neck (the ‘pseudocollar’). Visible cement fractures were found in 14%, none associated with focal lysis, which was seen in 11%.
406 hips in 365 patients remain under active follow up, with 122 patients (134 hips) deceased. Averaged clinical scores taken pre-operatively, 2 years post-operatively, and at latest follow-up show marked and sustained improvement: Charnley Pain 2.7, 5.5, 5.3; Charnley Function 2.1, 4.1, 3.6; Charnley Range of Motion 4.0, 5.4, 5.3; Harris Pain 19, 38, 36; Harris Function 18, 32, 28; and Oxford Hip Score 41, 22, 25. There have been 45 failures (8.3 percent) at an average 7.6 year follow up (range 2.6 – 15.3 years). Technical error contributed to 13 of the 24 non-infective complications, but with improved technique plus the addition of long stemmed impaction grafting, there have been no technical errors since 1996.
Retention of well fixed bone cement at the time of a revision THA is an attractive proposition, as its removal can be difficult, time consuming and may result in extensive bone stock loss or fracture. Previously reported poor results of cemented revision THA, however, have tended to discourage Surgeons from performing “cement in cement” revisions, and this technique is not in widespread use. Since 1989, we have performed a cement within cement femoral stem revision on 354 occasions. The indications for in cement revision included facilitating acetabular revision, replacement of a monoblock stem with a damaged or incompatible head, revision of hemiarthroplasty to THA, component malposition and broken stem. Cement in cement revision was only performed in the presence of well fixed cement with an intact bone-cement interface. An Exeter polished tapered stem was cemented into the existing cement mantle on each occasion. Follow up of 5 years or longer is available for 175 cases, and over 8 years in 41. On no occasion has a cement in cement femoral stem had to be re-revised during this time for subsequent aseptic loosening. Advantages include preservation of bone stock, reduced operating time, improved acetabular exposure and early post operative full weight bearing mobilisation. This technique has not been used for 1 stage revision of infection. This experience has encouraged the refinement of this technique, including the development of a new short stem designed specifically for cement within cement revisions. This stem is designed to fit into an existing well fixed cement mantle of most designs of cemented femoral component or hemi-arthroplasty, with only limited preparation of the proximal mantle required. The new stem greatly simplifies cement in cement revision and minimises the risk of distal shaft perforation or fracture, which is otherwise a potential hazard when reaming out distal cement to accommodate a longer prosthesis.
The average age at operation of the survivors was 57.6 years. No significant radiological subsidence between the cement and bone was found. Mean subsidence between the stem and the cement was 2.15mm, most occurring in the first five years and in all but one being less than four. The maximum was 18mm (grade D cementing). Cementing grades were B in 65%, C in 27%, D in 8%. Resorption of the neck (13%) was associated with excessive socket wear or cement left over the cut surface of the neck (the ‘pseudocollar’). Visible cement fractures were found in 14%, none associated with focal lysis, which was seen in 11%.
Radiological analysis of the pre-operative, immediate post-operative and most recent follow-up radiographs was also performed. This included evaluation of the cement mantle and impacted allograft, stem subsidence within the cement mantle, presence of cortical healing and graft trabeculation on the follow-up radiographs, as well as appearance of radiolucencies and graft resorption.
There have been 45 failures (8.3 percent) at an average 7.6-year follow-up (range 2.6–15.3 years). Technical error contributed to 13 of the 24 non-infective complications, but with improved technique plus the addition of long stemmed impaction grafting, there have been no technical errors since 1996.
A comparison of the clinical status and outcome of a group of patients treated with tw-stage revision using either excision arthroplasty or an articulating spacer (the Kiwi Prostalac) as the first stage is presented. Clinical scores were obtained before revision, after the first stage, and after the second stage revision, along with the outcome of the success of the revision procedure in terms of eradication of the infection, from the two study groups. Seven patients received excision arthroplasty and eight were treated with the Kiwi Prostalac spacer, at the treating surgeon’s discretion. A comparison of the clinical status of the two groups will be presented at the varying stages of treatment, along with hospitalisation duration, and morbidity and ultimate outcome. Our results demonstrate that two-stage revision with an antibiotic cement-coated THJR prosthesis (The Kiwi Prostalac) is an effective and safe method of managing deep peri-prosthetic infection around a THJR with significant advantages to the patient.
Impaction bone grafting in conjunction with a cemented polished double-taper stem as a technique for revision of the femoral component was introduced in 1987 at our institution. As at January 2000, 540 cases in 487 patients had been performed by multiple surgeons. All procedures have been studied prospectively, and there are no patients lost to follow-up. We present the survivorship and outcome data for these patients. Survivorship at 15 years is 90.6 percent (95 percent confidence interval:88–93 percent). Four hundred and six hips in 365 patients remain under active follow up, with 122 patients (134 hips) deceased. Averaged clinical scores taken preoperatively, 2 years postoperatively and at latest follow up showed marked and sustained improvement: Charnley Pain 2.7, 5.5, 5.3; Charnley Function 2.1, 4.1, 3.6; Charnley Range of Motion 4.0, 5.4, 5.3; Harris Pain 19, 38, 36; Harris Function 18, 32, 28; and Oxford Hip Score 41, 22, 25. There have been 45 failures (8.3 percent) at an average 7.6 year follow up (range 2.6–15.3 years). Technical error contributed to 13 of the 24 non-infective complications, but with improved technique plus the addition of long stemmed impaction grafting, there have been no technical errors since 1996. Our results show that revision of the femoral component with impaction bone grafting is a reliable and durable technique with an acceptably low complication rate with excellent survivorship at 15 years.
In relation to the conduct of this study, one or more the authors have received, or are likely to receive direct material benefits.
To establish the efficacy of femoral impaction grafting in femoral reconstruction following sepsis, we identified and reviewed all cases of two stage hip revision for sepsis in which femoral impaction grafting was used in the second stage, performed in Exeter from 1989 until the end of 1998. All patients underwent a Girdlestone excisional arthroplasty, were prescribed local and systemic antibiotic treatment, and then subsequently underwent surgical reconstruction, using femoral impaction grafting. These 53 cases represent a subgroup of our patients who had received a two-stage revision for infection during that period. The other patients did not require femoral grafting. 4 patients died within 24 months of surgery. 4 patients became reinfected (7.5%), and 1 patient underwent stem revision for a fracture below the tip of the stem at 10 months, leaving 44 patients with an average of 53 months follow up (range 24 to 122 months). These 44 patients all demonstrated improved clinical scores and satisfactory radiological outcomes. Our clinical results reveal post-operative scores approaching those for primary arthroplasty. Our intermediate term results justify the use of fresh frozen allograft bone in the second stage of revisional hip surgery for its low incidence of reinfection and loosening, and potential to improve bone stock.
We report the histology of a femur retrieved 3.5 years after a cemented revision of a hip replacement in which impaction allografting had been used to fill two large cortical defects. The allograft chips had largely been replaced by viable cortical bone, and the interface between cement and tissue resembled that seen after primary cemented arthroplasty.
We report the results of using impacted cancellous allografts and cement for fixation of the femoral component when revision arthroplasty is required in the face of lost bone stock. In 56 hips reviewed after 18 to 49 months there were few complications and a majority of satisfactory results with evidence of incorporation of the graft. Further study and review are necessary, but the use of the method appears to be justified.