Aims. The Exeter V40 cemented femoral stem was first introduced in 2000. The largest single-centre analysis of this implant to date was published in 2018 by Westerman et al. Excellent results were reported at a minimum of ten years for the first 540 cases performed at the designer centre in the Exeter NHS Trust, with stem survivorship of 96.8%. The aim of this current study is to report long-term outcomes and survivorship for the Exeter V40 stem in a non-designer centre. Methods. All patients undergoing primary total hip arthroplasty using the Exeter V40 femoral stem between 1 January 2005 and 31 January 2010 were eligible for inclusion. Data were collected prospectively, with routine follow-up at six to 12 months, two years, five years, and ten years. Functional outcomes were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Outcome measures included data on all components in situ beyond ten years, death occurring within ten years with components in situ, and all-cause revision surgery. Results. A total of 829 stems in 745 patients were included in the dataset; 155 patients (20.8%) died within ten years, and of the remaining 664 stems, 648 stems (97.6%) remained in situ beyond ten years. For the 21 patients (2.5%) undergoing revision surgery, 16 femoral stems (1.9%) were revised and 18 acetabular components (2.2%) were revised. Indications for revision in order of decreasing frequency were infection (n = 6), pain (n = 6), aseptic component loosening (n = 3), periprosthetic fracture (n = 3), recurrent dislocation (n = 2), and noise production (ceramic-on-ceramic squeak) (n = 1). One patient was revised for aseptic stem loosening. The mean preoperative WOMAC score was 61 (SD 15.9) with a mean postoperative score of 20.4 (SD 19.3) (n = 732; 88.3%). Conclusion. The Exeter V40 cemented femoral stem demonstrates excellent functional outcomes and survival when used in a high volume non-designer centre. Outcomes are comparable to those of its serially validated predecessor, the Exeter Universal stem. Cite this article: Bone Jt Open 2020;1-12:743–748

Aims

Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30 to 150 microinches. Results. Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results and Kaplan-Meier survivorship ranges from 90% to 99.5% in the best case scenario were noted at 10 to 20 year follow-up. Conclusion. With a properly-designed femoral stem, good cement technique, proper cement mantle, and surface roughness of 30 to 40 microinches, the cemented femoral stem provides a durable hip replacement in patients 60 to 80 years old with up to 95% survivorship at 10 to 20 year follow-up

Acetabular fractures present a challenge. Anatomical reduction can be achieved by open reduction and internal fixation (ORIF). However, in elderly patients with complex fracture patterns and osteoporotic bone stock, “fix and replace” has become an option in the management of these injuries. This involves ORIF of the acetabulum to enable insertion of a press fit cup and subsequent cemented femoral stem at the index surgery. A Retrospective analysis of all operatively managed acetabular fractures by a regional Pelvic and Acetabular Trauma service (01/01/2018-30/05/2023) STATA used for analysis. 34 patients undergoing “fix and replace” surgery. Of the 133 patients managed with ORIF, 21 subsequently required Total Hip Arthroplasty (THA). Mean follow up was 2.7 years versus 5.1. There was no statistical significance between the two groups with regards to BMI or sex. Mean age in the “fix and replace” group was 68 compared to 48 in the ORIF and subsequent THA group. This reached statistical significance between the two groups (p=0.001).ASA and Charlson Comorbidity Index (3 and 3 in “fix and replace” and 2 and 1.2 in ORIF to THA group) and Charlson Comorbidity Index both were statistically significantly different (p=0.006 and p=0.027, respectively). High energy mechanism of injury accounted for 56% of the “fix and replace” group compared to 48% in the ORIF to THA. 74% of “fix and replace” were associated fractures compared to 53% of ORIF to THA. Wait to surgery was 3 days for “fix and replace” while 186 days was the mean wait time from listing to THA for the ORIF to THA group. Complication rate was 41% versus 43% in the two groups. 14% in the ORIF to THA group developed PJI versus 6% in “fix and replace”. Fix and replace allows early mobilisation in frailer, elderly patients. Our results show fewer returns to theatre and less PJI in patients having arthroplasty as part of “fix and replace” than subsequent to Open reduction internal fixation

The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different. In the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group. Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success. The author's personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups. The author's current indication for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection. Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component. The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is an extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000. A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems, unfortunately, may continue to go down as it is uncommonly taught in residency and fellowship, however, it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons armamentarium when treating patients undergoing primary and revision THA

Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30–150 microinches. RESULTS. Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results and Kaplan-Meier survivorship ranged from 90–99.5% in the best case scenario were noted at 10–20-year follow-up. CONCLUSION. With a properly-designed femoral stem, good cement technique, proper cement mantle, and surface roughness of 30–40 microinches, the cemented femoral stem provides a durable hip replacement in patients 60–80 years old with up to 95% survivorship at 10–20-year follow-up

The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different, in the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group. Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success. The authors' personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups. The authors' current indications for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection. Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component. The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is a extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000. A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems unfortunately may continue to go down as it is uncommonly taught in residency and fellowship, however it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons' armamentarium when treating patients undergoing primary and revision THA

A) Mastering the Art of Cemented Femoral Stem Fixation. Introduction: Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multifactorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30–150 microinches. Results: Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results were noted and Kaplan-Meier survivorship ranged from 90% to 99.5% in the best case scenario at 10–20 year follow-up. Conclusion: With a properly-designed femoral stem, good cement technique, proper cement mantle, and surface roughness of 30–40 microinches, the cemented femoral stem provides a durable hip replacement in patients 60 to 80 years of age with up to 95% survivorship at 10 to 20 years. B) Cemented Primary Acetabulum. Introduction: I am going to present a technique of cementing an all-polyethylene socket, a brief review of our clinical experience, and all-polyethylene socket design features. Since 1991, we have been using direct compression molded polyethylene sockets. The minimum thickness of polyethylene is 8 mm. We keep the socket orientation at 45 degrees of lateral opening and 15 degrees of anteversion. The preparation of the socket involves multiple fixation holes with Midas Rex. The bone is cleaned with water lavage and heated cement. Radiographic Features: The cement/bone interface has been classified into three types on radiographs. Type 1 has a perfect merge of the cement into the cancellous bone in all three zones. Type III interface shows radiolucency in one or more zones. A commonly asked question is, “is this technique reproducible?” The answer is yes. Our Data: We have looked at our all-polyethylene socket from 1992 to 1998 and the total number of hips are over 1,000, with a follow-up of 2–8 years. We have not revised a single socket for fixation failure. Summary: A cemented socket is indicated in patients 60 years and older with a diagnosis of osteoarthritis. Relative contraindications are excessive bleeding, extensive cyst formation, weak cancellous bone such as in rheumatoid, JRA, DDH, and protrusion patients. Cemented THA in patients 60 years and older with DJD and molded all-polyethylene cup have provided the best results in terms of a high degree of reproducibility, high quality of function, and durability

Background. Radiostereometric Analysis (RSA) is an accurate measure of implant migration following total joint replacement surgery. Early implant migration predicts later loosening and implant failure, with RSA a proven short-term predictor of long-term survivorship. The proximal migration of an acetabular cup has been demonstrated to be a surrogate measure of component loosening and the associated risk of revision. RSA was used to assess migration of the R3 acetabular component which utilises an enhanced porous ingrowth surface. Migration of the R3 acetabular component was also assessed when comparing the fixation technique of the femoral stems implanted. Methods. Twenty patients undergoing primary total hip arthroplasty were implanted with the R3 acetabular cup. The median age was 70 years (range, 53–87 years). During surgery tantalum markers were inserted into the acetabulum and the outer rim of the polyliner. RSA examinations were performed postoperatively at 4 to 5 days, 6, 12 and 24 months. Data was analysed for fourteen patients to determine the migration of the acetabular cup relative to the acetabulum. Of these fourteen patients, six were implanted with a cementless femoral stem and eight with a cemented femoral stem. Patients were clinically assessed using the Harris Hip Score (HHS) and Hip Disability and Osteoarthritis Outcome Score (HOOS) preoperatively and at 6, 12 and 24 months postoperatively. Results. RSA revealed no significant acetabular cup migration in all planes of translation and rotation with mean translations below 0.40 mm and mean rotations below 1 deg at 24 months. The data suggests that acetabular migration occurred primarily in the first 6 months postoperatively. We observed mean translations at 24 months of 0.36 mm (x-axis), 0.39 mm (y-axis) and 0.35 mm (z-axis). Mean rotations of 0.68 deg (x-axis), 0.99 deg (y-axis) and 0.77 deg (z-axis) were also observed at 24 months. Micromotion along the proximal-distal translation (y-axis) plane represented proximal migration of the acetabular component (Figure 1). On investigation of the femoral stems (cementless and cemented) implanted with the R3 acetabular cup, the mean proximal migration of the acetabular cup for both was 0.39 mm (CI 0.19–0.58). For cementless femoral stems a mean proximal migration of 0.45 mm (CI 0.09–0.98) and for cemented femoral stems a mean proximal migration of 0.35 mm (CI 0.24–0.45) were observed (Figure 1). A significant difference in the clinical assessment of patients when comparing pre-operative with 6, 12 and 24 months were also observed (p < 0.0001). All clinical assessments demonstrated equivalent results when comparing the post-operative follow-up time points and the R3 acetabular cup and stem combinations. Conclusions. Mean translations and rotations were higher than previously reported for acetabular components with the enhanced porous ingrowth surface. The magnitude of proximal migration 24 months postoperatively was within published ‘acceptable’ levels, albeit within the ‘at risk’ range of 0.2–1.0 mm. Comparison of the proximal migration for cementless and cemented femoral stems expressed similar outcomes, a trend also observed with the clinical assessments. These findings support further investigation and analysis of the R3 acetabular component

Mastering the Art of Cemented Femoral Stem Fixation: Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60 to 80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30 to 150 microinches. Cemented Primary Acetabulum: I am going to present a technique of cementing an all-poly socket. We have looked at our all-poly socket from 1992 to 1998 and the total number of hips are over 1,000, with a follow-up of 2 to 8 years. We have not revised a single socket for fixation failure

A) Mastering the Art of Cemented Femoral Stem Fixation. Abstract:. Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30 to 150µm. Results:. Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results and Kaplan-Meier survivorship ranged from 90% to 99.5% in the best case scenario were noted at 10–20 year follow-up. Conclusion:. With a properly-designed femoral stem, good cement technique, proper cement mantle, and surface roughness of 30–40 microinches, the cemented femoral stem provides a durable hip replacement in patients 60–80 years old with up to 95% survivorship at 10–20 year follow-up. B) Cemented Primary Acetabulum. Introduction:. I am going to present a technique of cementing an all-poly socket, a brief review of our clinical experience, and all-poly socket design features. Since 1991, we have been using direct compression molded polyethylene sockets. The minimum thickness of poly is 8mm. We keep the socket orientation at 45 degrees of lateral opening and 15 degrees of anteversion. The preparation of the socket involves multiple fixation holes with Midas Rex. The bone is cleaned with water lavage. The cement is pressurised at a doughy state. Radiographic Features: The cement/bone interface has been classified into three types of radiograph. Type 1 has a perfect merge of the cement into the cancellous bone in all three zones. Type III interface shows radiolucency in one or more zones. A commonly asked question is, “is this technique reproducible?” The answer is “yes”. Our Data: We have looked at our all-poly socket from 1992 to 1998 and the total number of hips are over 1,000, with a follow-up of 2–8 years. We have not revised a single socket for fixation failure. Summary: The indication are patients 60 years and older with a diagnosis of osteoarthritis. Relative contraindications are excessive bleeding, extensive cyst formation, weak cancellous bone such as in rheumatoid, JRA, DDH, and protrusio patients. Cemented THA in patients 60 years and older with DJD and molded all-poly cup have provided the best results in terms of a high degree of reproducibility, high quality of function, and durability

Introduction. In the United States, cementless femoral fixation remains the dominant mode of fixation for femoral neck fractures, despite strong worldwide registry data that supports cemented fixation. The reason for this discrepancy remains unknown, controversial and often difficult to compare due to multiple variables. The purpose of this study was to evaluate a matched cohort of patients undergoing arthroplasty for femoral neck fractures and assess outcomes of revisions, periprosthetic fractures and mortality. Methods. This is an exact matched cohort study. Cemented fixation cases were exact matched to cementless fixation cases in a 1:1 fashion based on age, sex and Charlson Comorbidity Index (CCI). Outcome variables included: revision for periprosthetic fracture; all cause revision and mortality at any time point; all cause revision and mortality within 1-year and within 90-days. The primary independent variable was femoral fixation (cemented, cementless) and covariates included race (black, white, other), ethnicity (hispanic, non-hispanic), teaching status (minor, major, nonteaching) and bedsize (1–99, 100–399, >=400). Chi-square tests and multivariable logistic regression models were used for statistical analysis. Results. A total of 64,283 femoral neck fractures were evaluated. 17,138 cementless femoral stems were matched exactly to cemented femoral stems based on age, gender and Charleston comorbidity index (CCI). In the multivariate logistic regression analysis, compared to cementless femoral fixation, cemented fixation was associated with a 20% reduction in overall revision (OR 0.796, 0.675–0.939), a 30% reduction in revision at 1 year (OR: 0.709, 0.589–0.854) and a 86% reduction in revision for periprosthetic fracture (OR: 0.144, 0.07–0.294). However, cemented stem fixation was associated with a 23% (OR: 1.33, 1.134–1.338) and 16% (OR: 1.232, 1.134–1.338) increase in mortality at 90 days and 1 year post op respectively. Conclusions. In this exact matched cohort study, risk of early revision and revision for PPFx was dramatically reduced at all time points with the use of cemented stem fixation for elective THA and FNF. However, the increased risk of 90d and 1 year mortality following cemented stem fixation in the elective population warrants further investigation

Introduction. In the setting of periprosthetic joint infection, the complete removal of implants and cement can be challenging with well-fixed, cemented implants about the knee. This can get especially complex in the setting of long cemented femoral stems. Osteotomies are well described in the proximal femur and tibia for removal of implants and cement. There is little information available on distal femoral osteotomies to facilitate knee implant and retained cement removal. Methods. We describe a novel anterolateral oblique distal femoral osteotomy for the removal of well-fixed, cemented components during resection knee arthroplasty that preserves vascularity to the osteotomized segment. Cadaveric anatomic vascular injection studies were performed to document vascularity of the osteotomized segment. Clinical examples, and results will be presented. Results. Anatomic vascular studies documented preserved vascularity to the osteotomized segment. In two patients intramedullary infected implant and cement was completely removed. At reimplantation and final followup the osteotomy was radiographically healed, implants well fixed, and no recurrent infections were noted. Conclusions. This osteotomy appears to be useful when removing well fixed, cemented femoral components during periprosthetic infection. Vascularity and union was preserved and obtained in all patients. For figures, tables, or references, please contact authors directly

Purpose. The purpose of this study is to evaluate the clinical outcomes and and radiological findings of primary total hip arthroplasty(THA) performed by using cemented polished femoral stem. Materials and Methods. We retrospectively reviewed 91 hips (84 patients) that had undergone primary THA with cemented polished femoral stem after follow-up more than 10 years. The mean age at surgery was 57 years old (47 to 75). Mean follow up period was 12. 8 years(10.1 to 14). Clinical evaluation was performed using Harris hip score. The radiographic evaluation was performed in terms of the cementing technique, including of subsidence within the cement mantle, radiolucent lines at the cement-bone or cement-stem interface, cortical hypertrophy, and calcar resorption. Results. At the final follow-up, mean Harris hip score had improved from 55.2 points to 93.2 points. Barrack classification was 50 cases in A grade, 32 cases in B grade, 9 cases in C grade. Except only one case, subsidence of femoral stem was observed less than 2mm. There were no progressing radiolucent line and loosening of femoral stem. Conclusion. Our results in this study show good outcome for cemented polished femoral stem at follow-up more than 10 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 in Exeter, we have performed a ‘cement within cement’ femoral stem revision on 354 occasions. An Exeter polished tapered stem has been cemented into the existing cement mantle on each occasion. Clinical and radiological follow up of 5 years or longer is available for 156 cases. On no occasion has a cement in cement femoral stem had to be re-revised during this time for subsequent aseptic loosening. This 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 components or hemi-arthroplasties, 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

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

In the 1960's Sir John Charnley introduced to clinical practice his low friction arthroplasty with a highly polished cemented femoral stem. The satisfactory long term results of this and other cemented stems support the use of polymethylmethacrylate (PMMA) for fixation. The constituents of PMMA remain virtually unchanged since the 1960s. However, in the last three decades, advances in the understanding of cement fixation, mixing techniques, application, pressurization, stem materials and design provided further improvements to the clinical results. The beneficial changes in cementing technique include femoral preparation to diminish interface bleeding, pulsatile lavage, reduced cement porosity by vacuum mixing, the use of a cement restrictor, pre-heating of the stem and polymer, retrograde canal filling and pressurization with a cement gun, stem centralization and stem geometries that increase the intramedullary pressure and penetration of PMMA into the cancellous structure of bone. Some other changes in cementing technique proved to be detrimental and were abandoned, such as the use of Boneloc cement that polymerised at a low temperature, and roughening and pre-coating of the stem surface. In the last two decades there has been a tendency towards an increased use of cementless femoral fixation for primary hip arthroplasty. The shift in the type of fixation followed the consistent, durable fixation obtained with uncemented acetabular cups, ease of implantation and the poor results of cemented femoral fixation of rough and pre-coated stems. Unlike cementless femoral fixation, modern cemented femoral fixation has numerous advantages: it is versatile, durable and can be used regardless of the diagnosis, proximal femoral geometry, natural neck version, and bone quality. It can be used in combination with antibiotics in patients with a history or predisposition for infection. Intra-operative femoral fractures are rare. However, the risk may be increased in collarless polished tapered stems. Post-operative thigh pain is extremely rare. Survivorship has not been surpassed by uncemented femoral fixation and it continues to be my preferred form of fixation. However, heavy, young, male patients may exhibit a slightly higher aseptic loosening rate

Background. Aseptic loosening of cemented femoral stems results from migration of wear particles along the bone-cement interface, producing a foreign body reaction. After cement insertion, blood back pressure can disrupt the bone-cement interface, enabling this spread of wear particles. Our study investigates whether altering timing and speed of stem insertion can reduce this risk. Methods. We inserted mock “C-Stem” femoral components (De Puy-Synthes), using Smartset HV cement (De Puy-Synthes) into artificial femora, fitted with proximal and distal pressure transducers. Cement insertion began two, three or four minutes after mixing. Cement pressures were then allowed to settle for one minute and the stems were then inserted over durations of 25, 60 or 90 seconds. Results. Quicker insertion led to high peak pressures; however insertion over 90 seconds at 4 and 5 minutes achieved more sustained pressures above blood back pressure. Slower insertion particularly improved proximal pressurisation. Furthermore when the stem was inserted over 90 seconds at 5 minutes then the cement pressures remained high after full insertion of the stem. Conclusions. Commonly, femoral stems are inserted rapidly. Our study demonstrates that by inserting the femoral stem more slowly, cement pressure can be maintained above blood back pressure for longer. We believe that after slower stem insertion, the higher cement viscosity enables the surgeon to maintain cement pressure, via the stem, sufficient to resist blood back pressure without inadvertently over inserting the stem. This safe and simple modification of cementing technique generates higher and more sustained cement pressures. Level of evidence. 3. Disclosures. Depuy-Synthes kindly provided the equipment used in the study. None of the authors received any payment or other benefits

In a society whereby the incidence of obesity is increasing and medico-legal implications of treatment failure are more frequently ending with the consulting doctor, clarity is required as to any restrictions placed on common orthopaedic implants by manufacturing companies. The aim of this study was to identify any restrictions placed on the commonly used femoral stem implants in total hip replacement (THR) surgery, by the manufacturers, based on patient weight. The United Kingdom (UK) National Joint Registry (NJR) was used to identify the five most commonly used cemented and uncemented femoral stem implants during 2012. The manufacturing companies responsible for these implants were asked to provide details of any weight restrictions placed on these implants. The Corail size 6 stem is the only implant to have a weight restriction (60Kg). All other stems, both cemented and uncemented, were free of any restrictions. Fatigue fracture of the femoral stem has been well documented in the literature, particularly involving the high nitrogen stainless steel cemented femoral stems and to a lesser extent the cemented cobalt chrome and uncemented femoral stems. In all cases excessive patient weight leading to increased cantilever bending of the femoral stem was thought to be a major factor contributing to the failure mechanism. From the current literature there is clearly an association between excessive patient weight and fatigue failure of the femoral stem. We suggest avoiding, where possible, the insertion of small stems (particularly cemented stems) and large offset stems (particularly those with a modular neck) in overweight patients

In the 1960s Sir John Charnley introduced to clinical practice his low friction arthroplasty with a highly polished cemented femoral stem. The satisfactory long term results of this and other cemented stems support the use of cement for fixation. The constituents of acrylic cement remained virtually unchanged since the 1960s. However, in the last three decades, advances in the understanding of cement fixation, mixing techniques, application, pressurization, stem materials and design provided further improvements in the clinical results. The technical changes in cementing technique that proved to be beneficial include femoral preparation to diminish interface bleeding, careful lavage, reduced cement porosity by vacuum mixing, a cement restrictor, pre-heating of the stem and polymer, retrograde canal filling and pressurization with a cement gun, stem centralization and stem geometries that increase the intramedullary pressure and intrusion into the bone of the cement. Some other changes proved to be detrimental and were abandoned, such as the use of Boneloc cement that polymerised at a low temperature, and roughening and pre-coating of stem surface. In recent years there has been a tendency towards an increased use of cementless femoral fixation for primary hip arthroplasty. The shift in the type of fixation followed the consistent, durable fixation obtained with uncemented acetabular cups, ease of implantation and the poor results of cemented femoral fixation of rough and precoated stems. Unlike cementless femoral fixation, modern cemented femoral fixation has numerous advantages: it's versatile, durable and can be used regardless of the diagnosis, proximal femoral geometry, natural neck version, and bone quality. It can be used in combination with antibiotics in patients with a history or predisposition for infection. Intraoperative femoral fractures and postoperative thigh pain are extremely rare. Survivorship has not been surpassed by uncemented femoral fixation and it continues to be my preferred form of fixation. However, heavy, young male patients may exhibit a slightly higher aseptic loosening rate