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The Exeter Hip: 40 years of innovation in total hip arthroplasty

R. S. M. Ling, A. J. C. Lee, G. A. Gie, A. J. Timperley, M. J. W. Hubble, J. R. Howell, S. L. Whitehouse pp. 370 Exeter: Exeter Hip Publishing, 2010 ISBN: 978-0-9564521-1-5

In the 1960s the United Kingdom led the world in hip arthroplasty. Various designs and philosophies developed, but by the end of that decade the Charnley hip had became the most widely used implant. Surgeons in Exeter preferred a posterior approach to the Charnley trochanteric osteotomy, but were unhappy with their results using the then available implants. So they collaborated with engineers from the University of Exeter to develop their own device, designed to be implanted through a posterior approach. This was launched in 1969.

As is often the case in the pioneering of a new technology, the understanding of the key aspects of the new technology was limited, and progress made by trial and error, with the errors leading to a better understanding of the technology. The introduction of this book gives a brief but fascinating account of just such a process; the material properties of polymethylmethacrylate (‘cement’) were poorly understood, the design that was initially developed to improve cement pressurisation happened to work well in what is now termed a ‘taper-slip’ manner. The behaviour of the matt finished stem was much less successful, which gave great insight into how the materials functioned in vivo, and the serendipity of the initial design was used to develop what has become the most successful cemented hip system today.

The initial chapters cover the basic science of cemented hip replacement using a metal on polyethylene bearing. There are also chapters on the basic science of bone grafting in general and impaction grafting in particular. These are followed by clinical chapters covering clinical and radiological assessment of the painful hip, which includes a brief but helpful section on femoral-acetabular impingement, including the MRI arthrographic assessment. There is a section on templating, but it is disappointing to see that the description of digital templating only mentions Orthoview. Other systems are available, such as TraumaCad, which uses a more accurate scaling system and would have deserved a mention.

There is a chapter on anaesthesia which I suspect will be glossed over by most surgeons reading this book, but is actually a useful guide to anaesthetic issues in hip replacement patients. The chapter on infection gives a good discussion of bacteria and antibiotics, but is very brief on operating theatre aspects; laminar flow and body exhaust suits are only mentioned as reducing infection risk, with no further discussion or references. The operating theatres in my (PFI) hospital were built without body exhaust systems; should I be worried? There is also little mention of the various rituals of different types of skin preparation and draping in routine patients.

The chapter on surgical approaches only describes the two most common approaches, posterior and direct-lateral (which I am more used to being called ‘Hardinge’). Not surprisingly, there is no mention of trochanteric osteotomy, but there is also no mention of the direct anterior approaches which are becoming used more frequently in Europe and the United States. There is an interesting discussion on dislocation following hip arthroplasty, reviewing both the international literature and the experience in Exeter, but with a disappointing conclusion that there is no safe zone for socket orientation.

It is clear from data in all the registries, and the chapter on clinical outcomes, that the results of the Exeter hip are generally very good, but if cemented hips are to work well then attention to detail is important. The chapters on instrumentation and surgical technique give a good description of just such detail. There is a chapter on navigation, but I suspect that this is the chapter which will be rendered obsolete most rapidly as navigation systems and technology evolve. There is a chapter on complex primary THR which gives brief mention of various factors which may complicate a primary THR. Revision techniques are well covered, with chapters on implant removal, cement-in cement revision and periprosthetic fractures. Not surprisingly, impaction grafting is particularly well covered, with discussion of different aspects being broken down into seven chapters.

This book is called The Exeter Hip, but it is much much more than a simple description of an implant. With seven editors and 49 authors from the UK, Ireland, USA, Australia, France and the Netherlands, it is a detailed guide to a whole philosophy of hip arthroplasty. It is an excellent reference for any trainees wanting to understand the basic science, and it will be useful for any surgeon embarking on a career in hip arthroplasty. Experienced hip surgeons will also find interesting insights into how other surgeons work and how they might want to modify their own practice. I wonder whether it will persuade any committed uncemented users to change (back) to cement. Probably not, but it may persuade the vacillators to become cementophiles.

S. Krikler

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