Aims. The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems. Methods. In this case-control study, 25 patients (22 female) at mean age of 78 years (70 to 89) received cemented Exeter short stem (case group). Cases were selected based on Dorr type A femora and matched first by Dorr type A and then age to a control cohort of 21 patients (11 female) at mean age of 74 years (70 to 89) who received with cemented Exeter standard stems (control group). Preoperatively, all patients had primary hip osteoarthritis and no osteoporosis as confirmed by dual X-ray absorptiometry scanning. Patients were followed with radiostereometry for evaluation of stem migration (primary endpoint), evaluation of cement quality, and Oxford Hip Score. Measurements were taken preoperatively, and at three, 12, and 24 months and a minimum five-year follow-up. Results. At three months, subsidence of the short stem -0.87 mm (95% confidence interval (CI) -1.07 to -0.67) was lower compared to the standard stem -1.59 mm (95% CI -1.82 to -1.36; p < 0.001). Both stems continued a similar pattern of subsidence until five-year follow-up. At five-year follow-up, the short stem had subsided mean -1.67 mm (95% CI -1.98 to -1.36) compared to mean -2.67 mm (95% CI -3.03 to -2.32) for the standard stem (p < 0.001). Subsidence was not influenced by preoperative bone quality (osteopenia vs normal) or cement mantle thickness. Conclusion. The standard Exeter stem had more early subsidence compared with the short Exeter stem in patients with Dorr type A femora, but thereafter a similar migration pattern of subsidence until minimum five years follow-up. Both the standard and the short Exeter stems subside. The standard stem subsides more compared to the short stem in Dorr type A femurs. Subsidence of the Exeter stems was not affected by cement mantle thickness. Cite this article: Bone Jt Open 2023;4(7):507–515

Aims. The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems. Methods. A systematic literature search was performed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. In parallel, we performed a retrospective single centre study of Exeter V40 femoral stem prosthetic fractures between April 2003 and June 2020. Results. There are 25 reported cases of such prosthetic fractures confined to small case series and case reports within the literature. We report an additional 19 cases to the literature (mean age 66.3 years (SD 11.7); 12 (63%) females; BMI 32.9 kg/m. 2. (SD 5.9)). The mean time from index procedure to fracture was 7.8 years (SD 3.6; 2.5 to 16.3). Exeter V40 stem fracture incidence was 0.15% and 1.21% for primary and revision arthroplasty, respectively. Incidence was significantly higher in revision arthroplasty (p < 0.001) and 125 mm length stems compared to ≥ 150 mm length stems (1.25% vs 0.13%, respectively; p < 0.001). When comparing different stem length cohorts, 125 mm short-stems were associated with stem-body fractures (92% vs 29%; p = 0.0095), earlier time to fracture (6.2 years vs 11.0 years; p = 0.0018), younger patient age at time of fracture (62.7 years vs 72.6 years; p = 0.037), and female sex (75% vs 43%; p = 0.326). Conclusion. This complication remains rare, although we report a significantly higher incidence at up to 17 years follow-up than in the literature. Short 125 mm length Exeter V40 stems undoubtedly have a role in restoring anatomy and biomechanics in smaller femoral geometries, although the surgeon has to appreciate the higher risk of stem fracture and the associated predisposing factors which may necessitate particular attention to surgical technique and planning. Cite this article: Bone Jt Open 2021;2(6):443–456

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

We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10–17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions – 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%). Cemented THA with the Exeter Contemporary Flanged cup and the Exeter stem is a durable combination with results that can be replicated outside of the design centre. The Exeter Contemporary Flanged cup has excellent survivorship at 15 years when used with the Exeter stem. Cemented THA with well-proven components should be considered the benchmark against which newer designs and materials should be compared

Although data on uncemented short stems are available, studies on cemented short-stemmed THAs are limited. These cemented short stems may have inferior long-term outcomes and higher femoral component fracture rates. Hence, we examined the long-term follow-up of cemented short Exeter stems used in primary THA. Within the Exeter stem range, 7 stems have a stem length of 125 mm or less. These stems are often used in small patients, in young patients with a narrow femoral canal or patients with anatomical abnormalities. Based on our local database, we included 394 consecutive cemented stems used in primary THA (n=333 patients) with a stem length ≤125 mm implanted in our tertiary referral center between 1993 and December 2021. We used the Dutch Arthroplasty Registry (LROI) to complete and cross-check the data. Kaplan-Meier survival analyses were performed to determine 20-year survival rates with stem revision for any reason, for septic loosening, for aseptic loosening and for femoral component fracture as endpoints. The proportion of male patients was 21% (n=83). Median age at surgery was 42 years (interquartile range: 30–55). The main indication for primary THA was childhood hip diseases (51%). The 20-year stem survival rate of the short stem was 85.4% (95% CI: 73.9–92.0) for revision for any reason and 96.2% (95%CI: 90.5–98.5) for revision for septic loosening. No stems were revised for aseptic femoral loosening. However, there were 4 stem fractures at 6.6, 11.6, 16.5 and 18.2 years of follow-up. The stem survival with femoral component fracture as endpoint was 92.7% (CI: 78.5–97.6) at 20 years. Cemented short Exeter stems in primary THA show acceptable survival rates at long-term follow-up. Although femoral component fracture is a rare complication of a cemented short Exeter stem, orthopaedic surgeons should be aware of its incidence and possible risk factors

Objectives. Our primary aim was to describe migration of the Exeter stem with a 32 mm head on highly crosslinked polyethylene and whether this is influenced by age. Our secondary aims were to assess functional outcome, satisfaction, activity, and bone mineral density (BMD) according to age. Patients and Methods. A prospective cohort study was conducted. Patients were recruited into three age groups: less than 65 years (n = 65), 65 to 74 years (n = 68), and 75 years and older (n = 67). There were 200 patients enrolled in the study, of whom 115 were female and 85 were male, with a mean age of 69.9 years (sd 9.5, 42 to 92). They were assessed preoperatively, and at three, 12 and, 24 months postoperatively. Stem migration was assessed using Einzel-Bild-Röntgen-Analyse (EBRA). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), EuroQol-5 domains questionnaire (EQ-5D), short form-36 questionnaire (SF-36,) and patient satisfaction were used to assess outcome. The Lower Extremity Activity Scale (LEAS), Timed Up and Go (TUG) test, and activPAL monitor (energy expelled, time lying/standing/walking and step count) were used to assess activity. The BMD was assessed in Gruen and Charnley zones. Results. Mean varus/valgus tilt was -0.77⁰ and axial subsidence was -1.20 mm. No significant difference was observed between age groups (p ⩾ 0.07). There was no difference according to age group for postoperative WOMAC (p ⩾ 0.11), HHS (p ⩾ 0.06), HOOS (p ⩾ 0.46), EQ-5D (p ⩾ 0.38), patient satisfaction (p ⩾ 0.05), or activPAL (p ⩾ 0.06). Patients 75 years and older had a worse SF-36 physical function (p = 0.01) and physical role (p = 0.03), LEAS score (p < 0.001), a shorter TUG (p = 0.01), and a lower BMD in Charnley zone 1 (p = 0.02). Conclusion. Exeter stem migration is within normal limits and is not influenced by age group. Functional outcome, patient satisfaction, activity level, and periprosthetic BMD are similar across all age groups. Cite this article: N. D. Clement, M. Bardgett, K. Merrie, S. Furtado, R. Bowman, D. J. Langton, D. J. Deehan, J. Holland. Cemented Exeter total hip arthroplasty with a 32 mm head on highly crosslinked polyethylene: Does age influence functional outcome, satisfaction, activity, stem migration, and periprosthetic bone mineral density? Bone Joint Res 2019;8:275–287. DOI: 10.1302/2046-3758.86.BJR-2018-0300.R1

The Exeter V40 femoral stem is the most implanted stem in the NJR for primary THA. In 2004, the 44/00/125 stem was released for use in “cement-in-cement” revision cases. It has however been used ‘off-label’ as a primary stem when, for example, patient anatomy requires a smaller stem with a 44mm offset. We aimed to investigate survival of this stem in comparison to others in the range when used in primary THAs recorded in the NJR. Analyses were performed using a dataset based on that used for the 2020 NJR annual report. Our exposure was the stem; the outcome was all-cause construct revision. Crude analyses were performed using Kaplan-Meier and adjusted using Cox models. The 44/00/125 stem was directly compared to other stems in the Exeter range. We analysed 330,732 primary THAs using the Exeter V40 stem comprising 34.5% of the 958,869 THAs with complete information from the start of the NJR to 31 December 2018. The 44/00/125 stem was implanted in 2,158 primary THAs with 67.5% in female patients and a mean age of 67.8. The 10-year revision estimate for the 44/00/125 stem was 4.9% (95%CI 3.6, 6.8) and in constructs using an Exeter V40 stem was 2.8% (95%CI 2.7, 2.8). Controlling for age, sex and ASA demonstrated an increased overall hazard of revision for constructs using the 44/00/125 stem compared to constructs using other Exeter V40 femoral stems (HR 1.8 (95%CI 1.4, 2.3)). Although the revision estimate is within the NICE 10-year benchmark, survivorship of constructs using the 44/00/125 stem appears to be lower than the rest of the Exeter V40 range. Attempts to control for age, sex and ASA will not take into account confounding by indication i.e. patients with more complex anatomy who may have a higher risk of revision. Surgeons and patients should be reassured by this but should be aware of the observed increased revision estimate and use the stem according to its indications

Recent NICE guidance recommends use of a well proven cemented femoral stem for hip hemiarthroplasty in management of fractured neck of femur. The Exeter Trauma Stem (ETS) has been designed based on the well proven Exeter hip stem. It has a double taper polished stem design, proclaimed to share geometry and surface finish with the Exeter hip. This study investigated the surface finish of the two stems in order to investigate the hypothesis that they were different. Two ETS and two Exeter stems were examined using a profilometer with a sensitivity of one nanometer. Macroscopic visual inspection showed that the two Exeter stems had significantly smoother surface finish than the ETS stems. The roughness average (RA) values on the ETS stems were approximately an order of magnitude higher than those of the Exeter stems, mean of 0.235μm compared with 0.025μm (p<0.0001). This difference in surface finish has implications for the biomechanical functioning of the stem. Previous change of the Exeter stem to a matt surface-finish in 1976 resulted in a significant increase in stem failure rates and an understanding of the importance of the polished surface-finish in order to function within a taper-slip philosophy. By changing the surface finish in the ETS stem, longevity of the implant may similarly be affected. Clinical results have yet to be published demonstrating this. We recommend the manufacturer reconsiders the surface finish of the ETS stem to ensure it functions as well as the Exeter primary stem with which it shares a design philosophy

Cement-in-cement femoral revision is a proven technique in revision total hip arthroplasty, with excellent results when using standard sized Exeter stems. The Exeter 44/00 125 mm short revision stem was introduced in 2004 to facilitate cement-in-cement revision. The stem is 25mm shorter and has a slimmer body to allow greater flexibility to adjust depth of insertion and version of the stem. However, it is not known if this change in stem length and size effects its longer term performance. We therefore reviewed the clinical outcome and survival of the Exeter 44/00 short stem used for cement-in-cement revision in our unit, with a minimum of 5 years follow up. 166 cases were performed between 2004 and 2010. 103 hips were available for 5 year clinical and radiological follow up, with 91 hips surviving to final review in 2017. At 5 years, 43 hips had died, 13 were revised and 7 were too frail to attend clinical review. The fate of all 166 hips were known and included in the survival analysis. Median clinical scores improved significantly. Sixteen hips required re-revision (infection 6, loose cup 3, periprosthetic fracture 3, instability 2, stem fracture with chronic infection 1 and pain 1). Kaplan-meier survival analysis revealed 100% survival for aseptic loosening, 96.8% survival for stem failure and 88.9% survival for all causes. This is the largest series with the longest follow up of the Exeter 44/00 short revision stem. The stem performs equally well as standard Exeter stems with regards to aseptic loosening. The single stem fracture occurred secondary to bone loss in chronic infection, highlighting the importance of providing adequate proximal support for the stem. Periprosthetic fracture occurred in 2.4% of this series of revision cases. Larger registry-based studies may provide additional information on the performance of this stem

Introduction. Historical studies have reported incidences of taper corrosion in retrieved MoP hips of 20–50%. These studies relied on visual assessments, rather than using modern analytical techniques. Patients/Materials and Methods. The Northern Retrieval Registry was initiated to routinely analyse all retrieved hips. The volumetric wear rates of retrieved Exeter head tapers were measured using a coordinate measuring machine using validated methods and compared to the available results obtained from an ongoing study of failed MoM prostheses. Power analysis suggested that we would need at least fifty Exeter head tapers to provide significant results. Non-parametric tests were used to assess differences. We have previously identified head diameter/offset/taper angle and taper surface roughness as variables associated with taper wear. The effect of bearing material combination remains unquantified. These design variables were entered into a multiple regression model following log normalisation of taper wear. Results. 56 consecutively retrieved Exeter head tapers underwent assessment. 36 were of size 28mm. Primary causes for revision were acetabular loosening/periprosthetic fractures. Mean duration in vivo was 87 (1 – 252) months. Median total volumetric wear was 0.29mm. 3. with a wear rate of 0.07mm. 3. /year. There were 353 MoMs. Median taper wear rates for 28mm MoM was 0.07, for 36mm was 0.11, for 38–44mm was 0.31, for 45 – 48mm was 0.52, for 49–52 was 0.55mm and for >52mm was 1.36mm. 3. /year. While Exeter taper wear was significantly lower than the MoM group as a whole (p<0.001), regression modelling indicated that bearing diameter had the greatest influence on taper wear. Discussion. Contrary to previous literature reports, significant material loss at the taper junction of conventional arthroplasties is not commonly observed. Exeter hips appear to be protected to some extent by the smaller head size and lower taper roughness when compared to contemporary MoM devices. The effect of the bearing combination remains under investigation

Background: -The excellent survivorship of the Exeter stem is thought, in part, to be related to limited subsidence of the stem within the cement mantle due to it’s polished, double taper design. The subsidence within the cement mantel is seen as a necessary part of the optimum transmission of load into the cement and hence the bone. The long Exeter stems do not all mimic the same double taper geometry as the standard 150mm stem. There is no published evidence that the long stem Exeter implant exhibits the same subsidence within the cement mantel as the standard stem. Method: -Using digitised x-rays and a computer aided design package we measured the subsidence of 35 standard Exeter stems and 40 long stems. Measurements were taken from the initial postoperative radiograph and repeated at intervals up to 5 years. The long stem implants were all used in cemented revisions without the use of impaction grafting. None of the implants exhibited radiological loosening at the last follow-up x-ray available. Results: -The analysis of the standard length stems illustrated that the method was able to demonstrate subsidence within the cement mantel, at rates comparable to that in the published literature. However the long stem implants exhibited a significantly reduced subsidence rate (at 12 months P< 0.0001). Conclusion: -This study suggests that the subsidence of the long stem Exeter implant does not mirror that of the standard length stem. The loss of the fully tapered geometry of the longer stem Exeter implants may account for the reduced subsidence of the implant at the prosthesis/cement interface. The longevity of the standard length stem is, to a certain extent, thought to arise from a limited subsidence at this interface. This raises concerns that the survivorship of the longer stem implants should not be extrapolated from the excellent results of its shorter length relation

The clinical results of the cemented Exeter stem in primary hip surgery have been excellent. The Exeter ‘philosophy’ has also been extended into the treatment of displaced intracapsular hip fractures with ‘cemented bipolars’ and the Exeter Trauma Stem (Howmedica). We have identified an increase in the number of periprosthetic fractures that we see around the Exeter stem. We have also identified a particular group of patients with comminuted fractures around ‘well fixed’ Exeter stems after primary hip surgery that present a particular difficult clinical problem. Prior to fracture, the stems are not loose, the cement mantle remains sound and bone quality surrounding the reconstruction is good, i.e. classifying it as a Vancouver B1. However the comminuted nature of the fracture makes reduction and fixation with traditional methods difficult. Therefore in these particular circumstances it is often better to manage these as B2 or even B3 fractures, with distal bypass and uncemented reconstruction. Over an eleven-year period since 1999, 185 patients have been admitted to Nottingham University Hospitals with a periprosthetic femoral fracture around a hip replacement. These patients were identified from a prospective database of all trauma patients admitted to the institution. Of these patients we have identified a cohort of 21 patients (11%) with a periprosthetic fracture around an Exeter polished stem. Hospital notes were independently reviewed and data retrieved. Outcome data was collected with end points of fracture union, re-revision surgery and death. Data was also collected on immediate and long term post-operative complications. The mean age was 76 years at time of fracture, and 52% were male. The mean duration between primary index surgery and fracture was 18 months (median 11 months). 15 patients were classified as Vancouver B1, and six as B2 fractures. Of the B1 fractures, 14 underwent fixation and one was treated non-operatively. Of the B2 fractures, four were revised, one was revised and fixed using a plate, and one was fixed using a double-plating technique. Prior to fracture, none of the implants were deemed loose although one patient was under review of a stress fracture which subsequently displaced. One patient died prior to fracture union. All the other patients subsequently went onto unite at a mean of 4 months. There were no deep infections, non- or malunions. No patient underwent further surgery. Dislocation occurred in one patient and a superficial wound infection occurred in one patient which responded to antibiotic treatment. Three other patients have subsequently died at seven, twelve and fifty-three months post fracture due to unrelated causes. In our series of patients, in addition to the more standard fracture patterns, we have identified a very much more comminuted fracture. Indeed, we have described the appearance as if the tapered stem behaves like an axe, splitting the proximal femur as a consequence of a direct axial load. As a consequence of the injury, the cement mantle itself is severely disrupted. There is significant comminution and soft tissue stripping, calling into question the viability of the residual fragments. Treatment of this type of fracture using a combination of plates, screws and cables is unlikely to provide a sufficiently sound reconstruction. In our experience we believe these fractures around previously ‘well fixed’ Exeter stems should be treated as B2/B3 injuries

Survivorship of the standard Exeter Universal cemented stem with revision of the femoral component for aseptic loosening as the endpoint has been reported as 100% at 12 years. A version for use in smaller femora, the Exeter 35.5 mm stem, was introduced in 1988. Although also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem. Between August 1988 and August 2003 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 (18 to 86) years with 73 patients under the age of 50 years. The diagnosis was osteoarthritis 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in 3, secondary to Perthes disease in 2 and avascular necrosis of the hip in 1 patient. The fate of every implant is known. At a median follow-up of 8 (5 to 19) years survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. 15 cases (7.8%) underwent further surgery – 11 for acetabular revision, 1 for stem fracture and 3 others. Although smaller than a standard Exeter Universal polished tapered cemented stem, with a shorter, slimmer taper, the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients

Favourable long-term results have been reported with the standard Exeter cemented stem. We report our experience with a version for use in smaller femora, the Exeter 35.5 mm stem. Although, also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem. Between August 1988 and August 2003, 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 years (18 to 86), with 73 patients under the age of 50 years. The diagnosis was osteoarthritis in 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in three, secondary to Perthes disease in two and avascular necrosis of the hip in one patient. The fate of every implant is known. At a median follow-up of 8 years (5 to 19), survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Fifteen cases (7.8%) underwent further surgery 11 for acetabular revision, one for stem fracture and three others. Although, smaller than a standard Exeter Universal polished tapered cemented stem—with a shorter, slimmer taper—the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients

The review of the first 325 Exeter Universal hips reported good long term survivorship despite the majority of cups being metal backed. We have reviewed the long term performance of the concentric all-polyethylene Exeter cups used with the Universal Exeter stem. Clinical and radiographic outcomes of 263 consecutive primary hip arthroplasties in 242 patients with mean age 66 years (range, 18 to 89) were reviewed. 118 cases subsequently died none of whom underwent a revision. Eighteen hips have been revised; thirteen for aseptic cup loosening, three for recurrent dislocation and two for deep infection. Three patients (four hips) were lost to follow-up. The minimum follow-up of the remaining 123 hips was 10 years (mean 13.3 years, range 10–17). Radiographs demonstrated 4 (4%) of the remaining acetabular prostheses were loose. The Kaplan Meier survivorship at 14.5 years with endpoint revision for all causes is 91.5% (95% CI 86.6 to 96.2%). With endpoint revision for aseptic cup loosening, survivorship is 93.3% (CI 88.8 to 97.8%). This series included a number of complex cases requiring bone blocks and/or chip autograft for acetabular deficiencies. The concentric all polythene Exeter cup and Exeter stem has excellent long term results particularly when factoring in the complexity of cases in this series

The review of the first 325 Exeter Universal hips reported good long term survivorship despite the majority of cups being metal backed. We have reviewed the long term performance of the concentric all-polyethylene Exeter cups used with the Universal Exeter stem. Clinical and radiographic outcomes of 263 consecutive primary hip arthroplasties in 242 patients with mean age 66 years (range, 18 to 89) were reviewed. 118 cases subsequently died none of whom underwent a revision. Eighteen hips have been revised; thirteen for aseptic cup loosening, three for recurrent dislocation and two for deep infection. Three patients (four hips) were lost to follow-up. The minimum follow-up of the remaining 123 hips was 10 years (mean 13.3 years, range 10–17). Radiographs demonstrated 6 (6%) of the remaining acetabular prostheses were loose. The Kaplan Meier survivorship at 14.5 years with endpoint revision for all causes is 91.5% (95% CI 86.6 to 96.2%). With endpoint revision for aseptic cup loosening, survivorship is 93.3% (CI 88.8 to 97.8%). This series included a number of complex cases requiring bone blocks and/or chip autograft for acetabular deficiencies. The concentric all polythene Exeter cup and Exeter stem has excellent long term results particularly when factoring in the complexity of cases in this series

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. Materials and Methods. We reviewed the survivorship with clinical and radiological outcomes of 138 consecutive cemented THR's in 113 patients ≤50 years. The pre-op diagnoses included Osteoarthritis (30%), DDH (25%), RA (9%) and Post traumatic OA (5%), and 31% of patients had previous surgery to the hip. All patients were followed up at 5 year intervals and there was no patient lost to follow up. Results. Mean age of the patients at the time of surgery was 41.6 (18–50) years. Mean follow up time was 21.6 (20–26) years. There were 93 survivors and 14 deceased patients, with 31 patients needing revision THR. The reasons for revision surgery included 28 cases revised for aseptic loosening of the cup, one patient with Gaucher's disease who developed localised lysis around the stem, one broken stem, and one case with infection. There were no cases of aseptic loosening of the Exeter stem. There were no radiologically loose stems in the surviving or deceased patients at the time of follow-up although 2 patients had radiological evidence of loosening of the cemented cup. Survivorship at 22 years was 75% at for revision for all causes and 98 % for revision of the stem aseptic loosening or lysis. Conclusion. The Exeter cemented THR performs very well in the young patient population, with very favourable survivorship of the Exeter stem in particular, though with less favourable survivorship of these historic cemented cups. This study provides good evidence for the increased use of the cemented Exeter stem in this population group

The Exeter (Howmedica Ltd) and Ultima-TPS (Depuy Ltd) implants are both collarless, polished, double-tapered, cemented femoral implants. The Exeter is manufactured in stainless steel and has an excellent long-term survivorship. The Ultima-TPS is manufactured in cobalt-chrome and has been recently introduced. The aim of this study was to compare the early performance of these implants in a 2-year randomised clinical trial. 65 patients with unilateral hip osteoarthritis were randomised to receive either the Exeter or TPS stem. All received a Charnley Cup. Outcome measures included the Oxford Hip Questionnaire, proximal femoral bone mineral density (BMD) measured by dual energy x-ray absorptiometry, and implant subsidence measured using EBRA. At 2 years 43 patients (66%) were reviewed. 22 patients (mean age 70 years, 16 female, BMI 27.9Kg/m. 2. ) received the TPS implant, and 21 patients (mean age 70 years, 15 female, BMI 28.9Kg/m. 2. ) received the Exeter implant. 19 patients withdrew for reasons unrelated to the study, 2 died, and 1 was withdrawn after deep wound infection. Complete Oxford hip scores were available pre-operatively and at 2 years in 37 patients (n=20 TPS). Median (IQR) pre-operative hip scores were 51 (43 to 54) and 48 (36 to 53) for the TPS and Exeter implants, respectively. At 2 years the hip scores improved to 24 (18 to 31) and 22 (16 to 31), respectively. There were no differences in scores between groups at each time-point. There were no differences in BMD between groups at pre-operative baseline, 3 months, 1 and 2 years (Gruen zones 1–7, all time-points; n=19 TPS, n=13 Exeter implants: P> 0.05). Maximum bone loss was seen in Gruen zone 7 at 2 years for bone implants (TPS-11%, Exeter -14%, P> 0.05). Measurement of subsidence over 2 years using EBRA was possible in 20 patients (n=7 TPS, n=13 Exeter). Mean subsidence at 2 years was 1.62mm for the TPS implant and 1.60mm for the Exeter implant (P> 0.05). There was no plain radiographic evidence of osteolysis in either group. These data suggest that the early performance of the two implants studied is similar. However, long-term survivorship data is required to confirm their equivalency

The Exeter totally collarless, double-tapered femoral component was developed in 1969 jointly at the School of Engineering at the University of Exeter and the old Princess Elizabeth Orthopaedic Hospital. At the time, in common with a number of implants in contemporary use, the new Exeter stem was manufactured from the rather ductile stainless steel EN58J. The original version of the Exeter stem had a polished surface. This feature was not part of the original design specification, but was demanded by the current British standard governing the use of EN58J in orthopaedic implants. At that time, no thought was given to the possibility that the surface finish of the stem might influence outcome. Used from 1970 to 1975, the original stems rarely came to need replacement because of loosening. The major complication was the incidence of stem fracture, first seen in 1973, which has reached 4% over a 25 to 30 year follow-up. A stronger stem was introduced at the beginning of 1976. This was manufactured from 316L. As there was no standard demanding a polished surface, this stem was manufactured with a surface two orders of magnitude rougher than the surface of the original polished Exeter stems. While the introduction of this stem almost completely solved the problem of stem fracture, with it appeared notable problems of femoral endosteal bone lysis and aseptic stem loosening, hardly seen with the original polished stems. The study of retrieved prostheses showed the matt surface stem to be prone to abrasive wear against the inside of the cement mantle, and that this phenomenon could lead both directly and indirectly to stem loosening. Unfortunately, a decade passed before the polished stem was re-introduced in 1986. A monobloc version was used until the beginning of 1988, when the modular Exeter Universal stem was introduced. With both the monobloc and modular versions of the polished Exeter stem, both aseptic loosening and localised endosteal bone lysis have become rare. Further retrieval studies have shown that in polished and matt Exeter stems the wear processes between stem and cement are fundamentally different. This difference may explain the substantial clinical difference in outcome between these two types of stem. These considerations lead to the view that abrasive stem wear in matt stems is probably a major cause of failure, and more important than failure of cement

The MAKO Robotic arm is a haptic robotic system that can be used to optimise performance during total hip arthroplasty (THA). We present the outcome of the first 40 robotic cases performed in an NHS foundation trust along with the technique of performing robotic THA in our unit. Forty consecutive patients undergoing robotic THA (rTHA) were compared to a case matched group of patients undergoing manual THA (m-THA). 2:1 blinded case matching was performed for age, sex, implants used (Trident uncemented socket and cemented Exeter stem, Stryker Mahwah, NJ, US) and surgeon grade. Comparisons were made for radiological positioning of implants, including leg length assessment, and patient reported functional outcome (PROMS). Pre- and post-operative radiographs were independently analysed by 2 authors. All patients underwent THA for a primary diagnosis of osteoarthritis. No significant difference between groups was identified for post-operative leg length discrepancy (LLD) although pre-operatively a significantly higher LLD was highlighted on the MAKO group, likely due to patient selection. Significantly lower post-operative socket version was identified in the MAKO cohort although no difference in post-operative cup inclination was noted. However, there was significantly larger variance in post-op LLD (p=0.024), cup version (p=0.004) and inclination (p=0.05) between groups indicating r-THA was significantly less variable (Levene's test for homogeneity of variance). There was no significant difference in the number of cases outside of Lewinnek's ‘safe’ zone for inclination (p=0.469), however, there were significantly more cases outside Lewinnek's ‘safe’ zone for version (12.5% vs 40.3%, p=0.002) in the m-THA group. We report the commencement of performance of MAKO robotic THA in an NHS institution. No problems with surgery were reported during our learning curve. Robotic THA cases had less variability in terms of implant positioning suggesting that the MAKO robot allows more accurate, less variable implant positioning with fewer outliers. Longer term follow-up of more cases is needed to identify whether this improved implant positioning has an effect on outcomes, but the initial results seem promising