Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.

Cite this article: Bone Joint J 2024;106-B(1):11–15.

In high-demand situations, modern thinking and experience in total hip arthroplasty (THA) favours the uncemented press-fit cup over its cemented counterpart. Before its regular use in 1996, a high-demand cemented stem was designed for use as a short revision stem with a press-fit cup, with or without impaction bone grafting, in active people, especially those over 55 years.

Conceptually, a collarless double-tapered highly polished design was preferred. The clip-on hollow centraliser was designed for 5-mm subsidence. The valgus stem, with cement superior to the shoulder, limited upward pistoning in the cement sleeve, creating less debris. The stiff upper and flexible distal part resulted in a decreased contribution from shear and an increased contribution from compression in load transfer from prosthesis to cement. Three sizes are available: G1, G2 and G3. A straight type is presently being developed for smaller patients with congenital dysplasia of the hip.

The stem, made by (Thornton Heavy Engineering Sheffield, United Kingdom), from Rex 734 stainless steel to ISO-2002 standards, tapers 10 mm to 12 mm (6°). All tolerances are adequate to handle Inox or Ceramic heads.

From April 1996 to December 2002, 278 stems were implanted in Dr Weber’s practice. The first 172 hip operations (168 patients) were studied. The mean age was 58.6 years. There were 137 primary hips and 25 revisions.

The mean follow-up period was 4.5 years (3 to 7). Three patients died with the prosthesis in situ. Two reoperations were done: one cup was revised for recurrent dislocation and one fracture below the step was successfully plated. Only three cases of subsidence were documented, all of them less than 3 mm. To date there have been no stem revisions.

The prosthesis, together with the stainless steel head and cross-linked cup, can be regarded as cost-effective and can be used routinely, as a high-demand prosthesis with press-fit cup, or as a short-revision prosthesis.

The initial success of modern total hip arthroplasty can in large part be attributed to the reliable fixation of the femoral component with the use of acrylic bone cement. Early success with cement led to a common pathway of development in North America and the European countries. Much of the early to mid-term research concentrated on refinement of variables related to the methodology and technique of cement fixation. Scandinavian registries were subsequently able to report on improved survivorship with better cementing technique. The net effect has been standardisation towards a small number of cemented implants with good long-term outcomes representing the majority of stems implanted in Sweden, for example.

In North America, during the mid-term development of THA in the late 1980's, the term “cement disease” was coined and the cemented THA saw a precipitous decline in use, now to the point where many American orthopaedic residents are completing training never having seen a cemented THA. Modern uncemented femoral components can now claim good long-term survivorship, perhaps now comparable to cemented fixation. However, this has come at a cost with respect to the premium expense applied to the implant itself as well as lineage of failed uncemented constructs. The last several years have seen a proliferation of uncemented implants, usually at a premium cost, with no demonstrated improvement in survivorship. Osteolysis has not been solved with uncemented implants and cement disease has largely been recognised as a misnomer.

Long-term outcomes of cemented femoral fixation have consistently demonstrated excellent survivorship, even in the younger age group. Cemented stems allow for variable positioning of the stem to allow for better soft tissue balancing, without the need for proximal modularity. Cemented stems are more forgiving and fail less often secondary to a reduced incidence of intra-operative complications, such as peri-prosthetic fracture. Cemented stems tend to be less expensive and also have the advantage of adding antimicrobial agents into the cement. This is important in emerging markets. The next iteration of orthopaedic innovation driven by the emerging markets may indeed be back to the future.

Key Points: The initial success of total hip arthroplasty was based on cemented femoral fixation. Long-term outcomes in the United States demonstrate good results for cemented femoral fixation. Despite this, cemented fixation is not frequently used in the United States. Results from multiple national joint replacement registries demonstrate superior long-term performance of cemented femoral fixation. European countries, perhaps because of the excellent results in the national registries, use cemented femoral fixation more often than not. Cemented femoral fixation is cost neutral if not less expensive and allows for the addition of antimicrobials. Cemented femoral fixation is perhaps easier to perform as the component can be potted in a range of positions as opposed to the position being dictated by the femoral anatomy.

Introduction: This study investigates the influence of surgical approach on the early migration of a cemented Total Hip Replacement (THR), assessed by Roentgen Stereo-photogrammetric Analysis (RSA). Rapid early migration has been correlated with premature implant failure.

Method: 46 patients awaiting THR were allocated into Posterior Approach (PA) and Lateral Approach (LA) groups. RSA was used to assess post-operative stem position and migration at 1 year. Post-operative gait was examined for a subgroup of patients.

Results: There was no difference in initial stem position within the medulla. Significant differences in distal migration were found; (LA 0.78±0.07mm and PA 1.27±0.15mm), p< 0.01. Posterior head migration for the PA group (0.78±0.18mm) was twice that for the LA group (0.46±0.08mm), p< 0.05. The PA group showed greater medial migration of the prosthesis tip (0.62±0.24mm), compared to the LA group (0.11±0.08mm), p< 0.05. During gait, the legs of the PA group were relatively internally rotated when compared to those of the LA group.

Discussion: The PA implants rotate internally and into valgus further than the LA implants. The starting positions of the prostheses were the same with similar cement and prostheses characteristics. We can infer that surgical approach and therefore muscle function have a significant effect upon component migration. During gait, the PA group has relatively internally rotated legs, probably due to short external rotator weakness. Hence, the internally rotating torque on the femoral stem will be larger, explaining the rapid migration in this direction. With the LA approach, the abductors are likely to be damaged. Therefore, the PA joint reaction force will be more laterally directed, explaining the higher coronal plane rotation rates seen in this group.

Conclusion: Profound differences exist in early migration, between the LA and PA. Different muscle function may account for this and probably influences long-term outcome.

Introduction

Varus positioning of cemented ‘composite beam’ stems is associated with increased risks of aseptic loosening and stem fracture. We investigated whether the incidence of varus malalignment of the Exeter polished, double taper design in a multicentre prospective study adversely affected outcome after total hip replacement (THR).

Purpose: Double-tapered polished cemented femoral stems have demonstrated excellent long-term clinical results, but subsidence with cement mantle fracture, distal stress transfer and proximal stress shielding persist as problems. Adding a third taper from broad lateral to narrow medial purportedly reduces subsidence and improves proximal bone loading and preservation. We report our independent experience with a triple-tapered collarless polished cemented stem.

Methods: Between May 1999 and July 2001, 66 C-Stems (DePuy, Warsaw, IN, USA) were implanted in 45 females and 15 males, with a mean age of 67 years (R 35–86) and mean weight of 77 Kg (R 42–117). Diagnoses were OA in 62, RA in 1, AVN in 2 and fracture in 1. Average follow-up was 58 months (R 45–71).

Results: Harris hip scores improved from a mean of 43 (R17–100) to 84 (R 10–100). SF36 and WOMAC scores improved similarly. Six hips dislocated, but there were no reoperations. Subsidence was less than 1 mm in all cases. There was no radiographic stress shielding. Bone quality was maintained, especially in the critical medial calcar region, with positive bone remodeling along radial stress lines and improvement over time of some bone-cement interfaces.

Conclusions: The C-Stem, a triple-tapered collarless polished cemented stem, engages the surrounding cement mantle in an axially stable manner, minimizing subsidence to within the creep tolerances of cement. The radial stresses so generated favorably load the proximal bone, stimulating positive bone remodeling and eliminating stress-shielding. The clinical results at short to mid-term follow-up in this non-designer series are outstanding.

Prosthesis migration and acetabular cup wear are useful short term measurement which may predict later implant outcome. However, the significance of the magnitude and pattern of the migration is very much dependent on the specific design studied. This study aimed to characterise patterns of migration by following four cemented femoral stem designs using Radiostereometry (RSA) within a prospective randomised longitudinal trial.

164 patients undergoing cemented femoral hip replacement for osteoarthritis were randomised to receive either an Exeter (Howmedica Stryker), Ultima Tapered Polished Stem (TPS) (Depuy), Ultima Straight Stem (USS) (Johnson and Johnson) or Elite Plus (Depuy) stem. Each subject received the OGEE PE cemented acetabular component (Depuy). RSA examinations were performed at 1 week and 6, 12, 18, 24 and 60 months post surgery. They were analysed using the UMRSA system (RSA Biomedical AB, Umea, Sweden), and our local geometric stem measurement software. 149 patients had RSA measurements available to 2 years, and 96 patients to 5 years. Differences were analysed using mixed linear modelling (SPSS).

Median linear proximal cup wear rate reduced to a minimum of 0.02-0.06mm/year in year two. Between 2 and 5 years the wear rate increased, being significantly higher for the Elite.

Cup migration was small but continuous. At 2 years it was median 0.3mm proximally, increasing to 0.5 mm at 5 years. Median rotations were less than 0.3 degrees.

Proximal migration was positive and increasing at all time points for all stems. For the tapered polished designs, while the overall magnitude was significantly higher, the rate of migration significantly decreased, whereas for the other stem designs it did not.

The TPS stem showed a tendency for posterior tilt which was significant compared to the other stems at 5 years.

All stems tended to retroversion, with the USS significantly less than the others and the Elite showing and relative increase at 5 years.

In summary migration patterns are characterised by the stem design, including where there were only small changes between designs. We are now testing measured migrations as predictors of outcome, and will continue to follow this group of patients to 10 years.

The role of surface finish on the survivorship of cemented stems is controversial. The purpose of this study is to prospectively evaluate the mid-term clinical and radiographic performance of a cohort of patients who underwent total hip replacement with two identical cemented femoral stems differing only in surface finish (VerSys, Zimmer, Warsaw, IN).

64 total hip replacements with a rough stem (Ra: 70–100 micro inches) and 138 total hip replacements with a satin finish stem (Ra: 20–25 micro inches) were followed clinically and radio graphically for 4 to 7 years. All surgeries were performed by one surgeon, during a period of 1 year, utilizing the same surgical approach and technique, ace tabular cup, cement type and cementing technique. The groups had similar demographics, diagnosis, preoperative clinical score, cement mantle quality, alignment, and length of follow up.

The preoperative and postoperative Hospital for Special Surgery Hip Score at last follow up of the patients with a successful operation was not significantly different among the two groups. Five hips in the rough group and none in the satin group developed aseptic loosening and required revision (p=0.0009). The femoral bone-cement interface revealed progressive radiolucent lines or osteolysis in 8 out of 64 rough stems and in 3 out of 138 satin stems (p=0.01). There were progressive radiolucenciesor osteolysis in 44 out of possible 448 Gruen zones in the rough surface group and in 8 out of possible 966 Gruen zones in the satin finish group(p< 0.001).

A rough, textured stem is more likely to fail at intermediate follow-up than a satin surface stem. We recommend that the surface of cemented stems should be satin or polished, with a Ra of less than 20 micro inches.

Cemented, polished, tapered stems have produced excellent results, but some early failures occur in younger patients. The CPS-Plus stem (Plus Orthopedics AG, Switzerland) is a polished double taper with rectangular cross section for improved rotational stability. A unique proximal stem centraliser increases cement pressurisation, assists alignment and creates an even cement mantle.

Radiostereometric analysis has demonstrated linear subsidence in a vertical plane, without any rotation or tilt. These features should improve implant durability. Midterm (5 years) results of a prospective international multicentre study are presented.

Materials and Methods: 222 patients (230 hips) were recruited to this IRB-approved study at three centres in the UK and two in Norway. Clinical and radiographic outcomes were assessed at regular intervals.

Results: 160 hips in 153 patients were available for full clinical and radiographic evaluation. 27 patients have died, 30 patients were unable to attend (outcome known) and 12 patients have not reached 5 years follow-up.

The mean Harris hip score improved from 42 preoperatively to 91. There have been no revisions for aseptic loosening and none of the stems have radiographic evidence of loosening. There has been one revision for deep sepsis. With revision for aseptic loosening as an endpoint, stem survivorship is 100%.

Conclusion: The design of the CPS-Plus stem attempts to address the issues of cement pressurization, rotational stability, and subsidence. Earlier laboratory studies have now been supplemented by this clinical evaluation, performed in a number of different centres by several surgeons, and the midterm results are very encouraging.

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive any payments or make agreements to provide such benefit from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other non profit organization with which the authors are affiliated or associated.

Background: We observed early osteolysis and loosening of the rough surface-cement stem with a second generation metal-on-metal articulation. This study was to investigate the possible etiologic role of stem loosening and osteolysis by examination of the surface of the rough blast cement and related periprosthetic tissues that have been retrieved at revision.

Methods: We retrospectively analyzed 39 hips (37 patients) with use of metasul metal-on-metal total hip arthroplasty. Of the femoral stem, rough surface-cement stem used in 18 hips and cementless Ti-alloy stem in 21 hips. The mean duration of follow-up was 10.2 years. Of these eight rough blast cement stem were revised, seven in loosening and one in recurrent dislocation. By using energy disperse spectroscope and back scattered electron image, histologic studies were performed to the samples of periprosthetic tissues. Skin patch tests for metal hypersensitivity were done to select patients.

Results: All of cementless stems and cups showed excellent results at the last follow-up. However, eight cement hips were revised. Light microscopy showed polishing effect on retrieval femoral stem affected by the rotational force. EDS and BSE image revealed that there were abundant cement and related metal particles with size of 5-10μm. However there were few metal particles and had greater size (20–100μm) in periprosthetic tissues. Histologic finding shows perivascular infiltration of lymphocytes and accumulation of macrophages No relation was found between skin patch test and loosening.

Conclusion: These findings raise the possibility that early osteolysis and loosening in patients with metal-on-metal hip replacement were associated with rough blast surface cement stem. These mixed particles such as Fe and Zr maybe trigger lymphocytic reactivity suggestive delayed type hypersensitive reaction. This study suggests that cement stem which have rough blasted surface should be considered in metal-on-metal total hip arthroplasty.

Level of Evidence: Therapeutic level III-1(case-control study). See instructions to authors for a complete description of level of evidence.

The role of surface finish on the survivorship of cemented stems is controversial. The purpose of this study is to prospectively evaluate the mid-term clinical and radiographic performance of a cohort of patients who underwent total hip replacement with two identical cemented femoral stems differing only in surface finish (VerSys, Zimmer, Warsaw, IN). 64 total hip replacements with a rough stem and 138 total hip replacements with a satin finish stem were followed clinically and radiographically for 4 to 7 years. All surgeries were performed by one surgeon. The groups had similar demographics, diagnosis, length of follow up, cement mantle quality and alignment. The preoperative and postoperative Hospital for Special Surgery Hip Score at last follow up was not significantly different among the two groups. Five hips in the rough group and none in the satin group developed aseptic loosening (p=0.0009). The femoral bone-cement interface revealed progressive radiolucent lines or osteolysis in 8 out of 64 rough stems and in 3 out of 138 satin stems (p=0.01). There were progressive radiolucencies or osteolysis in 44 out of possible 448 Gruen zones in the rough surface group and in 8 out of possible 966 Gruen zones in the satin finish group (p< 0.001). A rough, textured stem is more likely to fail at intermediate follow-up than a satin surface stem. We recommend that the surface of cemented stems should be satin or polished, with a Ra of less than 20 microinches.

The role of surface finish on the survivorship of cemented stems is controversial. The purpose of this study is to prospectively evaluate the mid-term clinical and radiographic performance of a cohort of patients who underwent total hip replacement with two identical cemented femoral stems differing only in surface finish (VerSys, Zimmer, Warsaw, IN). 64 total hip replacements with a rough stem (Ra: 70–100 microinches) and 138 total hip replacements with a satin finish stem (Ra: 20–25 microinches) were followed clinically and radiographically for 4 to 7 years. All surgeries were performed by one surgeon during a period of 1 year, utilizing the same surgical technique, acetabular cup, cement type and cementing technique. The groups had similar demographics, diagnosis, preoperative clinical score, cement mantle quality, alignment, and length of follow up. The preoperative and postoperative Hospital for Special Surgery Hip Score at last follow up of the patients with a successful operation was not significantly different among the two groups. Five hips in the rough group and none in the satin group developed aseptic loosening (p=0.0009). The femoral bone-cement interface revealed progressive radiolucent lines or osteolysis in 8 out of 64 rough stems and in 3 out of 138 satin stems (p=0.01). There were progressive radiolucencies or oste-olysis in 44 out of possible 448 Gruen zones in the rough surface group and in 8 out of possible 966 Gruen zones in the satin finish group (p< 0.001). A rough, textured stem is more likely to fail at intermediate follow-up than a satin surface stem. We recommend that the surface of cemented stems should be satin or polished, with a Ra of less than 20 microinches.

Introduction

The orthopaedic market offers more than two hundred different hip femoral stems. Of these, very few have undergone scientific studies with published results. The differences of designs of the stem are mainly related to surface texture and geometry sections. The development of a new cemented hip prosthesis is certainly a very hard task if aiming the improvement of actual performance.

We report a series of 668 patients (699 hips) with an average follow up of 10.5 years (range, 10–11 years) following THR using a cemented custom-made titanium femoral stem and a cemented high-density polyethyl-ene acetabular component. The fate of every implant is known.

The mean age at operation was 68 years (24 – 94 years). The indication for THR was as follows: primary OA (629), RA (18), AVN (10), intracapsular femoral neck fracture (5), Perthes disease (3), developmental hip dysplasia (2) and SUFE (1). The mean pre-operative Harris Hip Score was 19 (range 10 – 42).

One hundred and seventy-four patients (26%) were deceased at the time of their 10-year review. Four hundred and ninety-four patients were subsequently reviewed of which 88 patients (13%) were assessed by telephone review as they were too frail to attend.

The average 10-year Harris Hip Score was 92 (range 43 – 100). The average 10-year Oxford Hip Score was 19 (range 12 – 46). 99.2% reviewed at 10 years stated that they were satisfied with their THR.

Revision surgery occurred in 21 cases (3%). Seventeen femoral components were revised for infection, one for recurrent dislocation and one was iatrogenically loosened during socket revision. There were no cases of revision for aseptic loosening of the stem. Dislocation occurred in 18 cases, of which 4 became recurrent (0.6%). Six patients had a postoperative sciatic nerve palsy (0.9%) with 4 making a full recovery. There was one case of femoral nerve palsy. Eleven patients developed a DVT (1.6%). Six patients had a PE (0.9%) all of which were non-fatal. There were 16 deep and 3 superficial wound infections. Thirty-eight patients had symptomatic trochanteric bursitis post-surgery.

In conclusion, the 10-years results of the custom femoral stem are encouraging with an overall high level of patient satisfaction.

Cemented femoral stems with force closed fixation designs have shown good clinical results despite high early subsidence. A new triple-tapered stem in this category (C-stem AMT) was introduced in 2005. This study compares this new stem with an established stem of similar design (Exeter) in terms of migration (as measured using radiostereometric analysis), peri-prosthetic bone remodelling (measured using dual energy x-ray densitometry, DXA), Oxford Hip Score, and plain radiographs. . A total of 70 patients (70 hips) with a mean age of 66 years (53 to 78) were followed for two years. Owing to missing data of miscellaneous reasons, the final analysis represents data from 51 (RSA) and 65 (DXA) patients. Both stems showed a typical pattern of migration: Subsidence and retroversion that primarily occurred during the first three months. C-stem AMT subsided less during the first three months (p = 0.01), before stabilising at a subsidence rate similar to the Exeter stem from years one to two. The rate of migration into retroversion was slightly higher for C-stem AMT during the second year (p = 0.03). Whilst there were slight differences in movement patterns between the stems, the C-stem AMT exhibits good early clinical outcomes and displays a pattern of migration and bone remodelling that predicts good clinical performance. Cite this article: Bone Joint J 2015;97-B:755–61

Background. Cemented femoral stems have an excellent long-term outcome. Modern cement techniques should be used to optimize femoral stem fixation. Bleeding from the bone surface during cemented hip arthroplasty compromises the bone-cement interface. However, no studies have examined this bleeding in vivo nor the effect the different cleaning methods used. In the present study we evaluated bleeding patterns and efficacy of cleaning methods used in third generation cementing techniques. Methods. We prospectively performed a medulloscopy with a 10 mm laparoscope in 200 primary hip arthroplasties. Intramedullary bleeding was evaluated after femoral canal preparation and use of the different cleaning methods. The femoral canal was divided into three areas to facilitate comparison. The intramedullary bleeding was standardized on a four point scale. A non-parametric repeated measures ANOVA was used for statistical analysis. Results. Cotton swabs and brushes did not reduce the intramedullary bleeding significantly after broaching of the canal. Compared to these standard cleaning methods, pulsed lavage and the addition of brushing provided better blood removal (p<0.001). There was a trend, although not statistical significant (p=0.24), towards better canal cleaning if a canal filling tampon with suction was added. Arterial bleeding originating from the posterior wall of the canal was noticed in 26 cases (13 percent). These could only be controlled by diathermy tools. Conclusion. Most standard preparation techniques are insufficient to prepare the femoral canal before cement insertion. In case of severe intramedullary bleeding, an arterial bleeding should be ruled out and if necessary treated with the aid of diathermy tools. We recommend pulsed lavage combined with a brush and a canal filling tampon for femoral canal preparation in cemented primary hip arthroplasty for optimal reduction of intramedullary bleeding

Aims

Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA).

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.

Aims

Refobacin Bone Cement R and Palacos R + G bone cement were introduced to replace the original cement Refobacin Palacos R in 2005. Both cements were assumed to behave in a biomechanically similar fashion to the original cement. The primary aim of this study was to compare the migration of a polished triple-tapered femoral stem fixed with either Refobacin Bone Cement R or Palacos R + G bone cement. Repeated radiostereometric analysis was used to measure migration of the femoral head centre. The secondary aims were evaluation of cement mantle, stem positioning, and patient-reported outcome measures.

Aims

The aim of this study was to radiologically evaluate the quality of cement mantle and alignment achieved with a polished tapered cemented femoral stem inserted through the anterior approach and compared with the posterior approach.