Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision necessitate removal of all bone cement from the femur. In our two institutions, we have been using a cement-in-cement technique, leaving the distal femoral cement in selected cases for septic hip revision surgery.

Between February 2010 and September 2019, 89 patients with prosthetic hip infection underwent first or single stage procedures leaving the distal femoral cement in situ and performing a cement-in-cement revision. The mean patient age was 72.0 years (24–92). The median time from the last arthroplasty procedure was 29.0 months (1–294).

81 patients underwent revision using a cemented Exeter stem, 7 patients received an articulating spacer, and one patient underwent excision arthroplasty with the distal cement left in situ. Patients received clinical and radiographic follow-up with a mean of 42.8 months (range 11.0–120.1 months). Oxford hip scores were collected from each institution's existing databases.

9 patients (10.1%) died within one year of surgery. No deaths were directly related to joint infection or the surgery. One patient was lost to follow up before one year.

Of the remainder, 7 patients (8.9%) required further procedures for infection and were therefore considered to be treatment failures. 6 patients (7.6%) underwent planned second stage procedures with no recurrence of infection. 7 patients (8.9%) had further surgery for non-infective reasons. The Kaplan-Meier estimate of infection free survival at one year was 93.7% (95% CI 88.4 to 99.0%).

No patients underwent revision for stem loosening. Oxford hip scores were available at over one year postoperatively for 51 patients with a mean score of 30.6, and a mean gain of 11.9.

In our combined cohort of patients, cement-in-cement revision had an infection eradication rate of 91.1%. Patient selection is crucial, and the procedure can only be performed when there is a well-fixed cement mantle. However, when strict criteria are followed, this technique offers potential significant benefits to surgeons performing this challenging surgery, and more importantly the patients undergoing them.

Introduction

Analysis of registry data shows that few units achieve results better than 99·98% control limits. Implant selection is considered a predictor of outcome variation in joint replacement. We analysed the outcomes of a unit with statistically “better than expected” results and compared to all other units within the National Joint Registry for England, Wales, Northern Ireland and Isle of Man (NJR). We sought to determine whether improved implant survival following primary total hip replacement (THR) is a centre effect or mediated by implant selection.

Introduction

Varus alignment of the femoral component in total hip arthroplasty (THA) is thought to be a risk factor for implant loosening and early revision surgery. The purpose of this study was to evaluate whether the Exeter stem tolerates varus alignment and assess if this theoretical malalignment has an influence on clinical outcomes.

Introduction

Rationing of orthopaedic services is increasingly being used by Care Commissioning Groups (CCG) within the United Kingdom to restrict the numbers of patients being referred for Total Hip Arthroplasty (THA). In Devon, only patients with an Oxford Hip Score (OHS) less than 20 are referred on for specialist Orthopaedic Review. The aim of this study was to look at long term outcomes after THA to see if this rationing has any rational base to justify its use

The SPAIRE technique (Spare Piriformis And Internus, Repair Externus) involves a muscle sparing mini-posterior approach to the hip.

Evidence will be prevented that the principle function of the “short external rotator” muscle group is primarily as an abductor and extensor of the flexed hip and has a profound influenced on weight bearing rising and propulsive motions; also that details of the insertions of the piriformis tendon and conjoint insertion of obturator internus and the gemelli (the Quadriceps Coxa) have previously been poorly appreciated. We have developed a surgical technique (SPAIRE) during which the only tendon released, and subsequently repaired, is obturator externus.

The author has carried out the SPAIRE technique for all routine hip arthroplasties for the last 18 months. This cohort has been compared with a matched control group for a comprehensive array of outcome measures. Results show no disadvantage of using the technique. On-table stability is so impressive that when the SPAIRE technique has been used no postoperative restrictions whatsoever are placed on the patient who is immediately encouraged to exercise the hip through a full excursion of movement.

Fewer tendons are damaged using the SPAIRE technique than any other approach to the hip including Direct Anterior and Direct Superior approaches. Randomised prospective studies are on-going using objective measurements of Gait and muscle power as well as functional and patient reported outcomes to prove benefit of the SPAIRE technique. For hemiarthroplasty cases a separate RCT is being undertaken comparing the SPAIRE technique with a direct lateral approach. It is believed that this technique may become the default technique for hemi- and total- hip arthroplasty through a posterior approach and for all hip fracture arthroplasty cases.

The risk of dying following total hip replacement (THR) is low and has declined over the last decades. The influence of comorbidities and worse physical status on mortality leads to the idea that patient-reported health status may also be a predictor of mortality. Although this has not been demonstrated in THR surgery, some studies in other fields have reported an association. The aim of this study was to investigate the relationship between patient-reported health status before THR and the risk of dying up to 5 years post-operatively.

The Swedish Hip Arthroplasty Register runs a nationwide PROMs program including the EQ-5D questionnaire to routinely monitor patients undergoing THR in Sweden. For these analyses, we used register data on 42,862 patients with hip osteoarthritis operated with THR between 2008 and 2012. Relative survival ratio was calculated by dividing the observed survival in the patient group by age- and gender-adjusted expected survival of the general population. Multivariable modelling proceeded with time-transformed Cox proportional hazards. Pre-operative responses to the five EQ-5D dimensions along with age, gender, education status, year of surgery, and hospital type were used as independent variables.

As a group THR patients had a better survival than the general population. Broken down by the five EQ-5D dimensions we observed differentiated survival patters. For all dimensions, those reporting moderate problems (level 2) had higher mortality than those reporting no problems (level 1) and those reporting extreme problems (level 3) had higher mortality than those reporting level 1 or 2.

Worse health status according to the EQ-5D before THR is associated with higher mortality up to five years after surgery. The complexity of the interactions between different patient-factors associated with outcomes complicates accurate assessments of risks and expected benefits for individual patients. EQ-5D responses may be useful in a multifactorial individualized risk assessment before THR.

Prospectively collected data is an important source of information subjected to change over time. What surgeons were doing in 1999 might not be the case anymore in 2016 and this change in time also applies to a number of factors related to the performance and outcome of total hip replacement. We evaluated the evolution of factors related to the patient, the surgical procedure, socio-economy and various outcome parameters after merging the databases of the Swedish Hip Arthroplasty Register, Statistics Sweden and the National Board of Health and Welfare.

Data on 193,253 THRs (164,113 patients) operated between 1999 and 2012 were merged with databases including general information about the Swedish population and about hospital care. We studied the evolution of surgical volume, patient demographics, socio-economic factors, surgical factors, length of stay, mortality rate, adverse events, re-operation and revision rates and PROMs.

Most patients were operated because of primary osteoarthritis and this share increased further during the period at the expense of decreasing number of patients with inflammatory OA and hip fracture. Comorbidity and ASA scores increased for each year. The share of all cemented implants has dropped from 92% to 68% with a corresponding increase of all uncemented from 2% to 16%.

Length of stay decreased with about 50 percent to 4.5 days in 2012. The 30- and 90-day mortality rate dropped to 0.4% and 0.7%. Re-operation and revision rates at 2 years were lower in the more recent years. The postoperative PROMs are improving despite the preoperative pain scores getting worse.

Even in Sweden, always been considered as a very conservative country with regards to hip replacement surgery, the demographics of the patients, the comorbidities and the primary diagnosis for surgery are changing. Despite these changes the outcomes like mortality, re-operations, revisions and PROMs are improving.

When Radiolucent lines (RLL) are observed around cemented acetabular components, they may progress and be associated with loosening.

We reviewed the incidence and progression of RLLs around the Exeter Contemporary flanged acetabular component and compared our results with other published series.

We reviewed a consecutive series of 203 sockets with a minimum 10-year follow-up. Up to date radiographs were reviewed by 2 independent assessors for the presence, location and thickness of RLL and an assessment for loosening/migration was made. Initial post-operative radiographs were examined for any case with RLLs at review.

There were no revisions for aseptic loosening. 103 hips remained in situ with a minimum follow up of 10 years. Lucent lines were seen on 37/103 (36%) of hips with a mean follow up of 12.1 years (10.0–13.9 years). In these 37 hips, the lucency was present in one zone in 84%, two zones in 8% and all three zones in 8%.

Of the 37 hips with a RLL at minimum 10 years follow up, five exhibited a RLL immediately post-operatively. All 5 of these lines were initially isolated to zone 1 and progressed over the 10 years around at least 1 more zone. Only one line became circumferential, although the cup did not migrate.

Compared to previous papers (DeLee & Charnley, Hodgkinson and Garcia-Cimbrelo) the presence of RLL at 10 years is reduced in our series (table 2) and no cup migrated. All RLL seen in cups at both 10 years and immediate post-operatively in our series progressed (table 3), unlike in the previous studies. This reduction in lucent lines may be down to modern cementing techniques, cup design or a combination of both.

For any figures or tables, please contact the authors directly by clicking on ‘Info & Metrics’ above to access author contact details.

Introduction

Improvements in function after THA can be evaluated using validated health outcome surveys but studies have shown that PROMs are unreliable in following the progress of individuals. Formal gait lab analysis is expensive, time consuming and fixed in terms of location. Inertial Measurement Units (IMUs) containing accelerometers and gyroscopes can determine aspects of gait kinematics in a portable package and can be used in the outpatient setting (Figure 1). In this study multiple metrics describing gait were evaluated pre- and post THA and comparisons made with the normal population

Introduction

The Exeter Hip femoral component remains largely unchanged from the original design, introduced in 1970. It is a highly polished, modular, double tapered stem and has undergone various minor modifications to surface, modularity and most recently the taper; changed to the current V40^TM design in 2000.

The effect of any design modification cannot easily be foreseen and greater emphasis is now placed on ensuring appropriate monitoring for such implants.

Introduction

Post-operative gait abnormalities are recognized following total hip arthroplasty (THA). Despite global improvement in functional outcome, gait abnormality persists for a decade or more. In this study 3-dimensional gait analysis (3DGA) was performed using a portable system with Inertial Measurement Units (IMUs) to quantify this abnormality.

Introduction

We report on the outcome of a cemented flanged acetabular component at a minimum of 10 years post-operatively.

Introduction

There is sparse evidence regarding the survivorship beyond 20 years of both uncemented and cemented hip replacements in patients 50 years and under. We report a unique series reviewing 20–26 year follow-up of patients ≤50 years with cemented Exeter THR.

Introduction

Cemented stems have given good results with no difference in outcome when comparing taper slip and composite beam designs in short-term randomised trials. We aimed to ascertain differences in outcome between the different cemented design philosophies using a large-scale registry analysis.

The design of hip replacements is based on the morphology of the proximal femur. Populations living in hard water regions have higher levels of serum calcium and magnesium which promote bone mineralization. A case control study was performed comparing proximal femoral morphology in patients living in soft and hard water regions to determine whether the effect of water hardness had an implication in the future design of hip-prostheses.

The proximal femoral morphology of 2 groups of 70 aged and sex matched patients living in hard and soft water regions at mean age 72.24 (range, 50 to 87 years) were measured using an antero-posterior radiograph of the non-operated hip with magnification adjusted.

The medullary canal diameter at the level of the lesser trochanter was significantly wider in patients living in the hard water region (mean width 1.9 mm wider; p=0.003). No difference was found at the isthmus, Dorr index, or cortical bone ratio.

In conclusion proximal femoral morphology does differ: a wider medullary canal at the level of the lesser trochanter in hard water regions. This size difference is relatively small and is unlikely therefore to affect the mechanics of the current femoral stem prostheses components.

This study utilised NJR primary hip data from the 6^th Annual Report to determine the rate and indication for revision between cemented, uncemented, hybrid and resurfacing prosthetic groups. Regression analysis was performed to identify the influence of gender and ASA grade on these revision rates. Validity of the data was interrogated by exploring for episodes of misclassification.

Background

Since 1991 to 2008 approximately 800,000 Exeter stems have been sold worldwide with 80 reported cases of fracture (neck or stem). This study aimed to determine factors predisposing to fracture.

Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 Developmental Dysplasia of the Hip (DDH). Prospective evaluation of the use of subtrochanteric derotational femoral shortening with a cemented Exeter stem.

15 female patients (18 hips – 3 bilateral) with a mean age at time of operation of 51 years followed-up for a mean of 114 months (range 52 to 168). 16 cemented and 2 uncemented acetabular components were implanted. Exeter cemented DDH stems were used in all cases. No patient lost to follow up. All 18 Crowe IV hips reviewed. Charnley-D’Aubigne-Postel score for pain, function and range of movement were improved from a mean of 2-2-3 to 5-4-5 respectively. One osteotomy failed to unite at 14 months and revised successfully. Clinical healing was achieved at a mean of 6 months while radiological evidence of union at a mean of 9 months. The mean length of the excised segment was 3 cm and the mean true limb lengthening was 2 cm. 3.5mm DCP plate with unicortical screws was used to reduce the osteotomy, and intramedullary autografting performed in all cases. Mean subsidence was 1 mm and no stem was found to be loose at the latest follow up. No sciatic nerve palsy was observed and there were no post-operative dislocations.

Cemented Exeter femoral components perform well in the treatment of Crowe IV DDH with when a subtrochanteric derotational shortening osteotomy (SDSO) was necessary. A transverse osteotomy is necessary to achieve derotation and reduction can be maintained with a DCP plate. Intramedullary autografting prevents cement interposition at the osteotomy site and promotes healing.

Introduction: Total hip arthroplasty is one of the most frequently performed surgical procedures, with implants usually giving over 90% survival at 10 years. The failure rate is primarily due to aseptic loosening often associated with progressive bone stock loss. Impaction of cancellous morselized allografts with cement can be used for revision total hip arthroplasty in such cases. There is increasing interest in the use of synthetic bone graft substitutes as extenders to allograft due to the shortage and variable quality of allograft. A chemically-pure synthetic calcium phosphate (CaP) allograft extender is compared with allograft alone for acetabular and/or femoral revisions using the Impaction Grafting technique.

Methods: 96 hips in 94 patients underwent revision hip arthroplasty using impaction grafting at 4 sites. Hip revision using impaction grafting was carried out using the Exeter X-Change Instrumentation system, using an Exeter Stem and/or a cemented polyethylene cup. Patients were randomized to receive allograft or CaP plus allograft in a 50:50 volume. Clinical and radiographic assessment was conducted pre-operatively and immediately post-operatively and at 6, 12 and 24 months. Clinical assessments included Harris Hip, Oxford and Charnley modified Merle d’Aubigne scores. Clinical complications were also recorded. Radiographs were assessed for the graft quality, radiolucent lines, lyses or migration, and incorporation of graft. The X-rays were also independently reviewed by an experienced author.

Results: The mean age was 70.2 years (range 41–89 years) with 58 males and 36 females. A total of 40 femoral revisions and 88 acetabular revisions were conducted. There were 46 patients in the ApaPore group, 49 patients in the allograft group and 1 patient who received CaP/allograft and allograft for an acetabular and femoral revision respectively.

No deep infections or adverse events due to the CaP were reported, with no significant difference in complication rates including revision and re-operations. No significant difference in acetabular migration, femoral subsidence, radiolucencies and lyses between the groups was observed. The independent review found no difference between the groups in terms of migration. The bone density was apparently greater for the ApaPore group at 12 months (p=0.001) and 24 months (p=0.012) although the significance of this is unclear. No significant difference in the clinical measures was observed between the groups.

Conclusion: CaP is comparable with allograft in terms of performance and safety when used as an allograft extender for total hip revision arthroplasty using impaction grafting.

The demand for primary hip replacements has grown steadily over the past 20 years and continues to do so. The challenge is to deliver a high quality and cost-effective service by developing short-stay pathways to optimise patient care and outcome.

A four-day hip protocol was established, with attention to detail on analgesia, thrombo-prophylaxis, mobilisation and patient motivation. A multi-disciplinary team was trained to deliver the pathway on a designated ward for primary hip replacements with the aim to discharge patients on the third post-operative day (four day stay in total). Before the initiation of this audit our average stay for primary hips was nine days. The national average stay is 10.6 days, with the top 10 trusts averaging 6.7 days.

In the initial three-month trial, 66 hip replacements (39 females and 27 males) done by the hip team at Princess Elizabeth Orthopaedic Centre in Exeter were audited against the four-day hip protocol. Average age was 72.4 years (range 44 – 92 years). Two patients were discharged on the second post-operative day and another 15 patients on the third post-operative day. As a result, we managed to get 25.8% of the patients home within four days. Overall, the average length of stay was only 6.3 days.

In conclusion, while we only achieved our target in 25.8% of patients, the project improved our overall length of stay remarkably. It is clearly evident that a targeted pathway focused to patient care in all aspects using a multi-disciplinary approach can improve the overall service delivery.

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.

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.

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.

Material and Methods: Uniform and composite specimens were fabricated and were tested for bending, tensile and shear strength. Beam shaped specimens were fabricated for bending and tensile tests, cylindrical for shear. Seventeen beams and eight cylindrical specimens fabricated earlier (1988–2002) using the same moulds were available to form composite specimens. Old specimens were placed into the moulds and new cement was injected next to these. Specimens were allowed to polymerize at room temperature for 30 minutes and stored in saline at 37 °C for 6 weeks before testing. Specimens were tested in Lloyds EZ 20 machine with customized jig so that the junction was subjected to bending, tensile or shear force.

Results: Bending tests: The load and bending stress for new specimen was 80N and 47MPa as compared with 72N and 38MPa for composite specimens. 4 composite specimens failed though old cement, 3 through the junction and 1 through the new cement. There was no statistical difference in maximum load between uniform and composite specimens (p=.29). However there was a difference in the stress between uniform and composite specimens.

Tensile tests: The load and tensile stress for new specimen was 916N and 29MPa as compared with 795N and 24MPa for composite specimens. 7 composites failed through old cement, 1 through new cement and 1 at junction. There was difference in the load and stress of uniform specimens as compared with composite specimens.

Shear tests: The load and shear stress for new specimen was 2718N and 35MPa as compared with 2055N and 26MPa for composite specimens. There was significant difference in load as well as stress in uniform specimens as compared with composite specimens.

Discussion: This study demonstrates that composite specimens fail at 89.6% of bending load, 77.2% of tensile and 74.6% of shear load as compared with uniform new cement specimens. They have 81.4% of bending stress, 74.9% of tensile stress and 73.3% of shear stress at failure as compared with uniform specimens. Of more importance is the fact that only four of these composite specimens (23.5%) failed at the junction and the rest thirteen failed either through old cement (64.7%) or through new cement (11.8%).

Introduction: Scant amount of information is available on mechanical properties of composite specimens of old and new cement. In previous studies evaluating this, old samples were only few days old, unlike clinical situation, where the old cement is a few years old.

We evaluated short-term mechanical properties of composite specimens and compared these with new uniform specimens.

Material and Methods: Uniform and composite specimens were fabricated and were tested for bending, tensile and shear strength. Seventeen beams and eight cylindrical specimens fabricated earlier (median age 11.8 years) using same moulds were available to form composite specimens. Specimens were stored in saline at 37 °C for 6 weeks before testing.

Results: Bending tests: Load and bending stress for new specimen was 82.9N and 49.5MPa as compared with 74.3N and 40.3MPa for composite specimens. 4 composite specimens failed though old cement, 3 through junction and 1 through new cement. There was no statistical difference in maximum load (p, 0.3) or stress (P, 0.06) between uniform and composite specimens.

Tensile tests: Load and tensile stress for new specimen was 941.5N and 29.5MPa as compared with 726.9N and 22.1MPa. There was difference in the load and stress of uniform specimens as compared with composite specimens.

Shear tests: Load and shear stress for new specimen was 2692.9N and 34.5MPa as compared with 2009.9N and 25.3MPa. There was significant difference in load as well as stress in uniform specimens as compared with composite specimens.

Discussion: This study demonstrates that composite specimens fail at 89.6% of bending load, 77.2% of tensile and 74.6% of shear load as compared with uniform new cement specimens. Of more importance is the fact that only four of these composite specimens (23.5%) failed at the junction and the rest thirteen failed either through old cement (64.7%) or through new cement (11.8%).

Introduction: Removal of all foreign material is the normal practice at the time of revision arthroplasty for sepsis. However, removal of well fixed bone cement is time consuming, can result in significant bone stock loss and increases the risk of femoral shaft perforation or fracture. We report our results of 2 stage revision hip arthroplasty with retention of a well fixed femoral cement mantle.

Methods: If the femoral cement mantle demonstrated good osseo-integration at first stage it was left in-situ. Following Girdlestone excision arthroplasty (GEA), patients received local and systemic antibiotics and underwent reconstruction at a second stage. At the second stage the femoral component was cemented into the old mantle.

Results: 16 patients (M:F 5:11) had at least 3 years follow up (mean 80 months, range 43 to 91). 1 patient died of an unrelated cause at 53 months. Recurrence of infection was not suspected in this case. The mean time to first stage revision was 57 months (3 to 155). The mean time between first and second stages was 9 months (1 to 35). Organisms were identified in 14 (87.5%) cases (5 Staphylococcus Aureus, 4 Group-B Streptococcus, 2 Coagulase negative Staphylococcus, 2 Enterococcus Faecalis, 1 Escheria Coli). At second stage 5 (31.2%) acetabula were uncemented and 11 (68.8%) were cemented. There were 2 complications, 1 patient dislocated 41 days post-operatively and a second patient required an acetabular revision at 44 days for sudden loss of fixation. No evidence of infection was found at re-revision. Currently no patients are suspected of having a recurrence of infection.

Discussion: In-cement revision of the femoral component following GEA for sepsis is not associated with a higher rate of recurrence of infection. Advantages include a shorter operating time, reduced loss of bone stock, improved component fixation and a technically easier second stage procedure.

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 & Aims: To study the survivorship and subsidence patterns of the first 433 Exeter polished, totally collarless, double tapered, cemented stems that were inserted between November of 1970 and the end of 1975 by 16 different surgeons (13 of them in the training grades) utilising first generation cementing techniques.

Method: A survivorship study up to the 33rd year of follow-up, using the contingency table method, was performed for all 433 hips, the end-point being revision for aseptic stem loosening. Stem subsidence in relation to the cement and the bone was measured in all survivors by a single observer on digitised films (magnified 200%) using the Orthochart™ software. Stem subsidence, the grade of cementing, ‘calcar’ resorption, visible cement fractures, focal lysis and radiolucent lines at the interfaces were assessed.

Results: Of the 433 hips, 21 were revisions of previously failed hips. 21.7% of patients have had a re-operation of some sort including 3.69% for stem fracture, 3.46% for neck fracture (all from a group of 95 stems with excessively machined necks), 9% for aseptic cup loosening, 3.46% for aseptic stem loosening, 1.84% for infection and 0.23% for recurrent dislocation). For the overall series, with revision for aseptic stem loosening as the end-point, the survivorship is 91.42% (95%CI: 70.82 to 100%). When all cases lost to follow-up (28 hips) are regarded as failures, survivorship is 82.9% (95%CI: 58.37 to 100%).

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%.

Conclusions: Although 21.7% of patients in this series of the first 433 Exeter hips to be inserted in Exeter needed a re-operation of some sort, the stem rarely required surgery for aseptic loosening and was associated with benign long-term X-Ray appearances in spite of 1st generation cementing.

Introduction: 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.

Methods: 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.

Results: Survivorship at 15 years is 90.6 percent (95 percent confidence interval: 88–93 percent).

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.

Conclusion: 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.

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.

Introduction and Aims: To study the survivorship and subsidence patterns of the first 433 Exeter polished, totally collarless, double tapered, cemented stems that were inserted between November 1970 and the end of 1975 by 16 different surgeons (13 of them in the training grades) utilising first generation cementing techniques.

Method: A survivorship study up to the 33rd year of follow-up, using the contingency table method, was performed for all 433 hips, the end-point being revision for aseptic stem loosening (including also a ‘worst case’ scenario). Stem subsidence in relation to the cement and the bone was measured in all survivors by a single observer on digitised films (magnified 200%) using the Orthochart™ software. Repeated measurements allowed the analysis of intra-observer errors. Stem subsidence, the grade of cementing, ‘calcar’ resorption, visible cement fractures, focal lysis and radiolucent lines at the interfaces were assessed.

Results: Of the 433 hips, 21 were revisions of previously failed hips. 21.7% of patients have had a re-operation of some sort, including 3.69% for stem fracture, 3.46% for neck fracture (all from a group of 95 stems with excessively machined necks), 9% for aseptic cup loosening, 3.46% for aseptic stem loosening, 1.84% for infection and 0.23% for recurrent dislocation). For the overall series, with revision for aseptic stem loosening as the end-point, the survivorship is 91.42% (95%CI: 70.82 to 100%). When all cases lost to follow-up (28 hips) are regarded as failures, survivorship is 82.9% (95%CI: 58.37 to 100%).

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%.

Conclusion: Although 21.7% of patients in this series of the first 433 Exeter hips to be inserted in Exeter needed a re-operation of some sort, the stem rarely required surgery for aseptic loosening and was associated with benign long-term x-ray appearances in spite of 1st generation cementing.

Introduction and Aims: 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. The aim of this study is to report on the outcome, survivorship, complications and radiological analysis of the first consecutive 540 cases performed in Exeter.

Method: 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.

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.

Results: 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 pre-operatively, two 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.

Conclusion: 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.

Introduction and aims: To study the survivorship and subsidence patterns of the first 433 Exeter stems inserted between 1970 and 1975 by 16 different surgeons utilising first generation cementing techniques.

Method: A survivorship study up to the 33rd year of follow-up was performed, the end-point being revision for aseptic stem loosening. Stem subsidence was measured in all survivors, as well as assessing the grade of cementing, ‘calcar’ resorption, visible cement fractures, focal lysis and radiolucent lines at the interfaces.

Results: Of the 433 hips, 21 were revisions of previously failed hips. 21.7% of patients have had a re-operation of some sort including 3.69% for stem fracture, 3.46% for neck fracture (all from a group of 95 stems with excessively machined necks), 9% for aseptic cup loosening, 3.46% for aseptic stem loosening, 1.84% for infection and 0.23% for recurrent dislocation). For the overall series, with revision for aseptic stem loosening as the end-point, the survivorship is 91.42% (95%CI: 70.82 to 100%). The average age at operation of the survivors was 57.6 years. No significant bone-cement subsidence was found. Mean stem-cement subsidence was 2.15mm, most occurring in the first 5 years and in all but 1 being less than 4mm. 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%.

Conclusions: Although 21.7% of patients in this series of the first 433 Exeter hips to be inserted in Exeter needed a re-operation of some sort, the stem rarely required surgery for aseptic loosening and was associated with benign long-term X-Ray appearances in spite of 1st generation cementing.

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.

Introduction We report the results of cancellous femoral impaction grafting with cement in revision hip arthroplasty in all patients from the above centre, who had their surgery more than five years previously.

Methods Up to December 1994, 226 hips underwent femoral impaction grafting in 207 patients. No deaths were attributable to the revision surgery. Thirty-three patients with 35 functioning hips died with less than five years follow-up. Only one patient was lost to follow-up. All other patients have had clinical review by two of the authors (BH and HE) and a combined panel undertook radiological review.

Results Two hips (one percent) became infected at the time of their revision surgery. Twelve stems underwent a further surgical procedure for aseptic failure; 10 for treatment of fracture and two for mechanical loosening in the absence of fracture. Survivorship with any femoral re-operation for any cause as the end point was 90.5% (confidence interval 82 to 98% (Peto equation)) at 10 to 11 years. Using femoral re-operation for symptomatic aseptic mechanical loosening as the endpoint the survivorship was 99.1% (CI= 96–100) at the same follow-up. The technique used in our centre has been modified since this series with an increased use of longer stems with impacted allograft. The technique used in Exeter has evolved and there has been an increased awareness of the fundamental importance of gaining stability of the implant within the graft at the time of surgery.

Conclusion These results provide evidence of a successful technique in the intermediate to long term.

In relation to the conduct of this study, one or more the authors have received, or are likely to receive direct material benefits.

Aims: This study reports the results of all patients from our centre who underwent femoral impaction grafting more then five years previously. As a consequence of our experience our technique has been modified and the indications for impaction grafting have become clearer. Methods: 226 hips underwent femoral impaction grafting in 207 patients. No deaths were attributable to the revision surgery. 33 patients with 35 functioning hips died with less than 5 years follow up. Only one patient was lost to follow-up. There were two (1%) acute infections. Twelve stems underwent a further surgical procedure for aseptic failure – 10 for treatment of femoral fracture and 2 for mechanical loosening in the absence of fracture. Results: Survivorship with any femoral re-operation for any cause as the end point is 90.5% (Confidence Interval 82–98%) at 10–11 years. Using femoral re-operation for symptomatic aseptic mechanical loosening as the endpoint the survivorship was 99.1% (Confidence Interval 96–100%) at the same follow-up. Conclusions: As a consequence of our experience in this series our technique has been modified with an increased use of longer stems with impacted allograft. Long stems are indicated when the host bone around a short stem is significantly compromised, in cases of severe bone stock loss, or when a fracture occurs.

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.