Objective: The adequacy of the cement mantle around various designs of impaction-grafted stems has been compared and deemed inadequate around the Exeter system. Yet, good clinical results have been reported. The conventional wisdom of solid cement mantles has been also been questioned in recent reports by the low migration and high survival rates of stems inserted with a very thin cement mantle – the so called ‘French paradox’. We performed this study specifically to address two questions

Does cement mantle thickness affect cement penetration depth during impaction grafting? and

Materials and Methods: 12 composite femurs were prepared to mimic cavitary defect. Impaction grafting was done with morcellized freshly frozen porcine femoral condyles using Exeter X-change system. The size of tamp and prosthesis were independently varied creating tamp/stem mismatch to produce cement mantles with a nominal thickness of 0, 1, 2, 3 or 4 mm. Cyclical loading was done at 1 Hz for 2500 cycles at 2500 N. From the displacement data measured by 6 linear displacement transducers we calculated subsidence and retroversion. The solid cement mantle and the penetration depth into the graft were then measured along 16 points in each cut section of the femurs done at 1.5 cm intervals.

Results: There was a high correlation between tamp/stem mismatch (nominal mantle thickness) and actual mantle thickness (r=0.84). Average cement penetration into the graft for each prosthesis varied between 0.3 and 2.0 mm. Largest variations were proximally, where average penetration varied between 0.4 and 3.5 mm. A thicker solid cement mantle gave on average less cement penetration (r=−0.62). Stem subsidence after cyclic loading ranged from 0.4 to 2.5 mm and correlated significantly with tamp size (r=0.59, p< .05). However, better correlations were found with solid mantle thickness (r=0.90, p< 0.05) and cement penetration depth (r=−0.81). Stem retroversion after cyclic loading ranged from 0.1 to 2.0 degrees and correlated negatively with stem size (r=−0.53) but did not correlate with tamp size. Correlations with solid mantle thickness and cement penetration depth were not better than those with tamp size.

Discussion: Our study shows that a thinner mantle is associated with deeper cement penetration into the graft. This probably is due to the higher cement pressure generated during stem insertion when there is less space for the cement to escape. Better mechanical interlock with the higher cement penetration possibly explains the reduced subsidence with thin cement mantles. Our study also shows that stem retroversion is associated with stem size only, and is larger for thinner stems. This could be explained by thinner stems providing less resistance to torsional forces.