Standard practice in revision total hip replacement (THR) for periprosthetic fracture (PPF) is to remove all cement from the femoral canal prior to implantation of a new component. This can make the procedure time consuming and complex.

Since 1991 it has been our practice to preserve the old femoral cement where it remains well fixed to bone, even if the cement mantle is fractured, and to cement a new component into the old mantle.

We have reviewed the data of 48 consecutive patients, treated at our unit between 1991 and 2009, with a first PPF around a cemented primary THR stem where a cement in cement revision was performed. 8 hips were revised to a standard length stem, 39 hips to a long stem & 1 patient had the same stem reinserted. All fractures were reduced and held with cerclage wires or cables and four had supplementary plate fixation.

Full clinical and radiographic follow up was available in 38 patients & clinical or radiographic follow up in a further 6 patients. The other 4 patients. without follow up but whose outcome is known, have suffered no complications and are pain free. Of the remaining 44 patients, forty-two went on to union of the fracture and two have required further surgery for non-union. One patient has ongoing undiagnosed hip pain.

Our long term experience with cement in cement revision for periprosthetic femoral fractures shows that this is a viable technique with a low complication rate and high rate of union (95%) in what is generally regarded as a very difficult condition to treat.

Introduction

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

We present 346 consecutive revision procedures for aseptic loosening with acetabular impaction bone grafting (AIBG) and a cemented polyethylene cup. Defects were contained with mesh alone. Mean follow up of 6.6 years, range 8 days-13 years. The Oxford Hip (OHS) and Harris Hip (HHS) scores were collected prospectively. Radiological definition of cup failure was either > 5mm displacement, or > 5° rotation. Cox regression analysis was performed on ten separate patient and surgical factors to determine their significance on survivorship.

Kaplan Meier survivorship at 10 years (42 cases remaining at risk) for aseptic loosening was 87% (95% confidence Interval (CI): 81.6 to 92.2) and 85.6% (95% CI: 80.3 to 90.9) for all revisions. These results are comparable to other reported series utilising AIBG. However, there were 88 cases (25%) that exceeded the radiological migration parameters, but their functional scores were not significantly different to the non-migrators: OHS p=0.273, HHS p=0.16. The latest post-operative mean OHS was 33 (SD 10.66). Female gender (p=0.039), increasing graft thickness (p=0.006) and the use of mesh (p=0.037) were significant risk factors for revision, but differing techniques in graft preparation, including artificial graft expanders (p=0.73), had no significant effect when analysed using Cox regression.

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.

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.

Impaction bone grafting (IBG) of the acetabulum in cemented primary total hip replacement is a useful technique in the management of acetabular deficiencies. It has the capacity to restore anatomy and bone stock with good long-term outcome. We present 125 consecutive cases of IBG with a cemented polyethylene component. All patients who received full IBG of the acetabulum in primary cemented Exeter total hip replacements and who underwent surgery between August 1995 and August 2003 were identified. All operative and follow-up data was collected prospectively and no patients were lost to follow-up. All patients underwent pre-operative and regular post-operative hip scores with the Harris, Oxford and the modified Charnley scoring systems. Data on indication, surgical technique, socket position and migration and revision was reviewed at a mean follow-up of 7.6 (range 5 to13.4) years.

Between August 1995 and August 2003, 113 patients (85 females) with an average age of 67.8 (range 22.9–99.2) years underwent 125 primary Exeter cemented total hip replacements with IBG of acetabular defects. Acetabular defects were classified according to the AAOS classification as cavitatory in 62 hips and as segmental, requiring application of a rim mesh prior to IBG, in 63 hips. Life tables were constructed demonstrating 86.4% survival of the acetabular component at 13.4 years with revision for any reason as the endpoint and 89.3% survival with revision for aseptic loosening as the endpoint. Of the seven patients who underwent revision for aseptic loosening, all had pre-operative segmental acetabular defects requiring application of a rim mesh. No patient who underwent IBG for a cavitatory defect required revision surgery for aseptic loosening. Survival of the Exeter cemented femoral component was 100% at 13.4 years with revision for aseptic loosening as the endpoint. There were 11 radiographic failures of the acetabular component, which have not been revised at latest review. One of these is symptomatic but not fit for revision surgery, two were asymptomatic at time of death and eight are asymptomatic but under review.

This is the largest series of IBG in the acetabulum in cemented primary THR. Our results suggest that the medium term survival of this technique is good, particularly when used for cavitatory defects. Although there were radiographic failures, these are largely asymptomatic and may not require revision.

Removal of well-fixed cement at the time of revision THA for sepsis is time consuming and risks bone stock loss, femoral perforation or fracture. We report our experience of two-stage revision for infection in a series of cases in which we have retained well-fixed femoral cement.

All patients underwent two-stage revision for infection. At the first stage the prostheses and acetabular cement were removed but when the femoral cement mantle demonstrated good osseo-integration it was left in-situ. Following Girdlestone excision arthroplasty (GEA), patients received local antibiotics delivered by cement spacers, as well as systemic antibiotics. At the second stage the existing cement mantle was reamed, washed and dried and then a femoral component was cemented into the old mantle.

Sixteen patients (M:F 5:11) had at least three years follow-up (mean 80 months – range 43 to 91). One 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 nine months (1 to 35). Organisms were identified in 14 (87.5%) cases (5 Staphylococcus Aureas, 4 Group B Streptococcus, 2 Coagulase negative Staphylococcus, 2 Enterococcus Faecalis, 1 Escheria Coli). At second stage, five (31.2%) acetabulae were uncemented and 11 (68.8%) were cemented. There were two complications; one patient dislocated 41 days post-operatively and a second patient required an acetabular revision at 44 days for failure of fixation. No evidence of infection was found at re-revision. One patient (1/16, 7%) has been re-revised for recurrent infection. Currently no other patients are suspected of having a recurrence of infection (93%).

Retention of a well-fixed femoral cement mantle during two-stage revision for infection and subsequent cement-in-cement reconstruction appears safe with a success rate of 93%. Advantages include a shorter operating time, reduced loss of bone stock, improved component fixation and a technically easier second stage procedure.

Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 DDH. The objective was to perform a prospective evaluation of SDTSO with Cemented Exeter Femoral Component.

15 female patients (18 hips – 3 bilateral) with a mean age at time of operation of 51 years were followed-up for a mean of 77 months (11 to 133). 16 cemented and 2 uncemented acetabular components were implanted. Exeter cemented DDH stems were used in all cases. No patient was lost to follow-up.

Charnley-d'Aubigné-Postel scores 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 was revised successfully. Clinical healing was achieved at a mean of 6 months and radiological at a mean of 9 months. The mean length of the excised segment was 3cm and the mean true limb lengthening was 2cm. A 3.5mm DCP plate with unicortical screws was used to reduce the osteotomy, and intramedullary autografting was performed in all cases. Mean subsidence was 1mm and no stem was found loose at the latest follow-up. No sciatic nerve palsy was observed and no dislocation.

Cemented Exeter femoral components perform well in the treatment of Crowe IV DDH with SDTSO. 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.

Aim

The aim of this study was to determine the medium term survivorship and function of the Exeter Universal Hip Replacement when used in younger patients, a group that is deemed to place high demands on their arthroplasties. Since 1988 The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital. There were 130 Exeter Universal total hip replacements (THR) in 107 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. Mean age at surgery was 42 years (range 17-50 years.) Six patients who had 7 THRs had died, leaving 123 THRs for review. Patients were reviewed at an average of 12.5 years (range 10-17 years). No patient was lost to follow-up.

Purpose

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

Comparison of the safety and efficacy of Bilateral Simultaneous Total Hip Arthroplasty (BSTHA) with that of staged (SgTHA) and unilateral (UTHA) was conducted using DerSimonian–Laird heterogeneity meta-analysis. A review of the English-language literature identified 23 citations eligible for inclusion. A total of 2063 bilateral simultaneous THR patients were identified. Meta-analysis of homogenous data revealed that there were no statistically significant differences between rates of thromboembolic events (p=0.268 and p=0.365) and dislocation (p=0.877) when comparing staged or unilateral with bilateral simultaneous THR procedures. A systematic analysis of heterogenous data demonstrated that mean length of hospital stay was shorter after bilateral simultaneous THR. Blood loss was reduced after bilateral simultaneous THR in all studies except for one, and surgical time was not different between groups. This procedure was also found to be economically and functionally efficacious when performed by experienced surgeons in specialist centres.

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.

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.

The aim of this study was to evaluate the cost of implants used in a large series of peri-prosthetic femoral fractures and assess its financial impact in the era of Payment by Results

We evaluated the clinical demographic and economical data associated with 202 patients with peri-prosthetic fractures of the proximal femur in two orthopaedic centers of excellence. All fractures were classified preoperatively according to the Vancouver classification. The patients were followed up until radiographic confirmation of fracture union and post-operative outcome was recorded with reference to the patients’ mobility and any complications.

The mean age of the patients operated was 81.2 years (range 33–100 years). 55% of the patients in our series were graded type B3 and 25% type B2. 80% of all fractures underwent revision. 71 percent of the fractures united within 8.4 months. 112 patients had impaction femoral grafting. Our implant cost alone for revision varied from 1900 pounds to as high as 3500 pounds without taking in to account the cost of cement and allograft (femoral heads and struts).

Hospital resource utilization for peri-prosthetic fractures is quite high compared to the reimbursement received. This is due to hospital stay and rehabilitation needs, theatre utilization, implant cost and higher readmission rates. There are neither reference costs available nor any special tariffs for these complex fractures. The reimbursement for internal fixation of these fractures could range from £2336 to £4230 and for emergency revision hip replacement is £5928. More than 50% of the reimbursement money would just be necessary to meet the implant costs. For uncemented revisions this equation is even worse. Current HRG codes for the treatment of peri-prosthetic fractures are unrealistic and new treatment algorithms and special tariffs have to be introduced to help manage these fractures.

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 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.

Comparison of the safety and efficacy of Bilateral Simultaneous Total Hip Arthroplasty (BSTHA) with that of staged (SgTHA) and unilateral (UTHA) was conducted using DerSimonian–Laird heterogeneity meta-analysis. Twenty three citations were eligible for inclusion. A total of 2063 BSTHA patients were identified. Meta-analysis of homogenous data revealed that there were no statistically significant differences between rates of thromboembolic events (p=0.268 and p=0.356) and dislocation (p=0.877) when comparing SgTHA or UTHA versus BSTHA procedures. Systematic analysis of heterogenous data demonstrated that mean length of stay was shorter in BSTHA as compared to SgTHA and UTHA procedure, blood loss was lower in BSTHA in all studies except one, whilst the surgical time was not different between groups. BSTHA was also found to be economically and functionally efficacious.

There is evidence that recommends the retention of a well-fixed cement mantle at the time of revision hip arthroplasty. The cement-cement interface has been proven to have a greater shear strength than a new bone-cement interface after removing the old cement mantle.

This study reviewed a series of acetabular revision procedures with a minimum 2 year follow-up where the original cement mantle was left intact. From 1988 to 2004, 61 consecutive cement-in-cement revisions of the acetabular component were performed at our institution. Outcome was based on functional assessment using the Oxford, Charnley, and Harris scoring systems as well as radiographic analysis using the DeLee and Charnley criteria.

In total 61 procedures were performed in 59 patients (40 female and 19 male), whose mean age at surgery was 75 years (range 40 to 99 years). 47 hips (77%) were performed for recurrent dislocation, 12 for polyethylene wear associated with other reasons for revision (aseptic stem loosening in 8, stem fracture in 2, femoral periprosthetic fracture in 1, subluxation in 1), 1 for unexplained pain, and 1 for disarticulation (intraprosthetic dislocation) of a constrained liner. No case was lost to follow-up. There was a significant improvement in the functional scores from the pre-operative status with the patients maintaining a low level of pain. There was one re-revision for aseptic cup loosening at 7 years, with 1 further case of radiological loosening identified at the latest review. There were 6 further cases of dislocation 4 of which were treated with further in-cement revisions. All other cases showed well-fixed components on radiographic analysis and no evidence of failure at the most recent follow up.

The cement-in-cement revision technique can be used in selected cases of acetabular revision surgery, providing satisfactory functional outcomes backed up by good radiographic results. Blood loss and surgical time are also significantly decreased.

Objectives: Retrospective case control study of management and outcome of periprosthetic femoral fractures, from the lower limb reconstruction unit in Exeter.

Material and Methods: 144 fractures over a period of 20 years were reviewed. The Vancouver classification system wasd used to clasify the fractures. The prosthesis length was measured pre and post-peratively. The use of impaction grafting technique for inadequate bone quality of the surrounding bone was assessed (type B3 fractures). The use of Dall/Miles, DCP and Mennen plates was also assessed. Healing was defined using radiological and clinical criteria and where available the Harris Hip Score. Chi-square test with p< 0.05 was used for the statistical analysis of the Results:

Results: When the Vancouver system was applied 2.85% of the fractures were classified as type A, 87.2% as type B and 10% as type C. Within the type B group 13.2% were subtype B1, 12% subtype B2 and 62% subtype B3. 1 out of 6 Mennen, 4 out of 16 Dall/Miles and 2 out of 20 DCP plates failed. Overall 68% healing, 5% non-union, 4% infection, 23% re-fracture rate at 12 months follow-up. Better healing was achieved when impaction grafting was used for B3 fractures (p=0.001). Better healing was achieved when the revision stem was bypassing the most distal fracture line by at least 2 ipsilateral femoral diameters and impaction grafting was used for B3 fractuires (p=0.01).

Conclusion: Impaction Grafting can compensate for the inadequate bone in type B3 fractures and appears to promote union. Revision stem should bypass the most distal fracture line by at least 2 cortical diameters to achieve healing.