Introduction: We describe an update of our experience with the implantation of the first 325 Exeter Universal hips. The fate of every implant was known.

Methods: This is a review of the prospective data collected from the first 325 Exeter Universal stems (309 patients) inserted between March 1988 and February 1990. The procedures were undertaken by surgeons of widely differing experience. Clinical and radiological review was performed at a mean of 15.4 years.

Results: At last review 185 patients had died (192 hips). 104 hips remain in-situ. Survivorship at 17 years with revision for femoral component aseptic loosening was 100% (95% CI 97 to 100), with revision for acetabular component aseptic loosening was 92.85% (95% CI 87.0 to 96.2) and with any re-operation as the endpoint was 83.99% (95% CI 77.1 to 90.27). 12 patients (12 hips) were not able to attend for review due to infirmity or emigration, and scores were obtained by phone (x-rays were obtained in 4 patients). Mean D’Aubigné and Postel scores (Charnley modification) at review were 5.4 for pain and 4.5 for function. The mean Oxford score was 21.46 +/− 9.52 and the mean Harris score 73.35 +/− 17.32. On radiological review there were no femoral component failures. Three sockets (2.9%) were loose as demonstrated by migration or change in orientation (two patients were asymptomatic) and 5 sockets (4.8%) had radiolucent lines in all 3 zones but no migration. There are two patients awaiting socket revision.

Discussion: The high rate of clinical and radiological success of the Exeter Universal stem seen at 12 years is sustained at 17 years. Further cup failures have occurred but overall survivorship remains good. With the favourable long-term behaviour of the original Exeter stem, we feel optimistic that good function of the Universal stem will continue through the third decade.

Introduction: Concerns have been raised regarding both the risk of non-union, and the ability to achieve stability with the use of an ETO in combination with cemented femoral impaction allografting.

Objective: To evaluate the long term follow-up results on all patients using ETO with Impaction Grafting.

Material and Methods: Eighteen patients with a mean age of 61 years were prospectively evaluated. The mean follow-up was 60 months (13 – 114). Charnley-D’aubigne-Postel scores, stem length, ETO length, ETO healing and complications were recorded. No patient was lost to follow-up.

Results: In 13 cases the femur was classified as Paprosky type 3B, in 1 case type 3A and in 4 cases type 4. The mean femoral diameter was 25 mm and the mean osteotomy length was 130 mm. In all cases the stem bypassed the distal osteotomy site with a mean of 58 mm (mean ratio to femoral diameter 2.3). Radiological and clinical healing were achieved in all cases at a mean of 6 months. No evidence of graft-host subsidence or lack of femoral stability was observed.

Conclusion: Further to bone augmentation, Impaction Grafting when performed appropriately protects the osteotomy site from cement interposition leading to a secure bony union of the osteotomy site. The distal osteotomy site should be bypassed by at least 2 ipsilateral femoral diameters. The presence of an ETO did not appear to affect graft stability.

In the years 1990–1993, in an effort to reduce waiting list time, a small number of patients were sent from Exeter to hospitals in London to undergo elective total hip replacement. No medium- or long-term follow-up was arranged. Our aim was to audit the outcome of these hip replacements.

Review of the records of the referring medical practices, Regional Health Authority, local Orthopaedic Hospital and the distant centres at which the surgery was performed has identified 31 cases. A total of 27 hip replacements in 24 patients were available for clinical and radiological review.

12 (44%) hips have so far required revision surgery, at a mean of 6.5 years. Of these, three (11%) have been for deep infection. A further three hips (11%) are radiologically loose and are being closely monitored. Two patients (7%) suffered permanent sciatic nerve palsy.

Patients whose surgery was performed locally over a similar time period have a published failure rate of only 4.6%. The causes for such a difference in outcome were analysed and include surgical technique, implant selection and absence of follow-up. In the light of this evidence, we would like to urge the government to address waiting list problems by investing in the local infrastructure. Expanding those facilities where properly audited and fully accountable surgeons operate must be the way forward.

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.

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.