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.

Stems may improve fixation and stability of components during revision total knee replacement. However, the choice between cemented and cementless stems is not a clear one. Cemented stems offer several advantages in terms of versatility, mechanical stability, surgical technique and clinical outcome over their cementless counterpart.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):115–7.

A: - determine the incidence of intraoperative periprosthetic femoral fracture (PFF)

B: - determine the incidence of, and the reoperation rate for postoperative PFF

When using either CC or PTS femoral components.

Retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All PFFs were identified using regional radiograph archiving and electronic care systems.

Of the 11,018 THAs 4,952 were CC and 6,066 were PTS. Between groups, age, sex, and BMI did not differ.

A: - 55 (0.5%) had an intraoperative PFF. 44 CC and 11 PTS (p<0.001). 3 patients in each group had a femoral shaft fracture, remaining fractures were either the calcar (20 CC and 2 group) or the greater trochanter (11 CC and 6 PTS).

B: - 91(0.8%) sustained a postoperative PFF. Of those 15 were managed conservatively, 15 were revised and 61 (80.3%) had an ORIF. The CC group had both a lower overall rate of postoperative PFFs (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.341), and a lower rate of return to theatre (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). 1.3% of male PTS (36/2,674) had a reoperation compared to 0.3% of male CC (7/2,121) (p<0.001).

With regard to stem fracture there were none in the Corail group and 5 in the Exeter group. Of these 2 were sub trunnion and 3 were basal neck.

A: - There were significantly more intraoperative PFFs with CC 44 (0.8%) than PTS 11 (0.2%). However, the majority of fractures were either of the calcar or greater trochanter with no impact on early recovery or one year Oxford scores.

B: - Male PTS were five times more likely to have a reoperation for postoperative PFF. Females had the same incidence of reoperation with either component type.

There were 5 stem fractures in the Exeter group and none in the Corail.

These results represent robust estimates, which are likely to be more accurate than revision only studies typically generated from registry data.

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

The well-fixed cemented femoral stem and surrounding cement can be challenging to remove. Success requires evaluation of the quality of the cement mantle (interface lucency), position of the stem, extent of cement below the tip of the stem and skill with the specialised instruments and techniques needed to remove the stem and cement without perforating the femur. Smooth surfaced stems can usually be easily removed from the surrounding cement mantle with a variety of stem extractors that attach to the trunnion or an extraction hole on the implant. Roughened stems can be freed from the surrounding cement mantle with osteotomes or a narrow high speed burr and then extracted with the above instruments. Following this, the well-fixed cement mantle needs to be removed.

Adequate exposure and visualization of the cement column is essential to remove the well-fixed cement without damage to the bone in the femur. This is important since fixation of a revision femoral component typically requires at least 4 cm of contact with supportive cortical bone, which can be difficult to obtain if the femur is perforated or if the isthmus damaged. Proximally, cement in the metaphyseal region can be thinned with a high speed burr, then split radially and removed piecemeal. It is essential to remember that both osteotomes and high speed burrs will cut thru bone easier than cement and use of these instruments poses a substantial risk of unintended bone removal and perforation of the femur if done improperly. These instruments should, as a result, be used under direct vision.

Removal of more distal cement in the femur typically requires use of an extended femoral osteotomy (ETO) to allow for adequate access to the well-fixed cement in the bowed femoral canal. An ETO also facilitates more efficient removal of cement in the proximal femur. The ETO should be carefully planned so that it is distal enough to allow for access to the end of the cement column and still allow for stable fixation of a new implant. Too short of an ETO increases the risk of femoral perforation since the straight cement removal instruments cannot negotiate the bowed femoral canal to access the end of the cement column without risk of perforation. An ETO that is too distal makes cement removal easier, but may not allow for sufficient fixation of a new revision femoral stem. Cement below the level of the ETO cannot be directly visualised and specialised instruments are necessary to safely remove this distal cement. Radiofrequency cement removal devices use high frequency (ultrasonic) radio waves to melt the cement within the canal. Although cement removal with these devices is time consuming and tedious, they do substantially reduce the chances of femoral perforation. These devices can, however, generate considerable heat locally and can result in thermal injury to the bone and surrounding tissues. Once the distal end of the cement mantle is penetrated, backbiting or hooked curettes can be use to remove any remaining cement from within the canal. It is important that all cement be removed from the femur since reamers used for preparation of the distal canal will be deflected by any retained cement, which could result in eccentric reaming and inadvertent perforation of the femur and make fixation of a new implant very challenging. An intra-operative x-ray can be very helpful to insure that all cement has been removed before reaming is initiated.

One should always plan for a possible femoral perforation and have cortical strut grafts and a stem available that will safely bypass the end of the cement column and the previous cement restrictor.

The use of a cemented implant instead of a spacer has been proposed due to the improved function in comparison with a spacer. Unfortunately the removal of a conventional cemented stem can be challenging. The use of a short cemented stem can overcome this problem.

Between July 2011 and May 2013, 10 infected hips were treated with a short cemented stem as a spacer. The infected implants were cemented in 6 cases and cementless in 4 cases. Mean time from index operation was 3 years (range 0 to 8 years). It was the first treatment for infection in all cases. Antibiotic loaded cement and an all-poly cup was used in all cases. The bugs were staph aureus and staph epidermidis in most cases. A Friendly short cemented stem with specific cement restrictor and standard cementing tecnique was used in all cases. This stem has been successfully tested in over 200 patients and approved by TUV to be released on the marked.

In all cases, the infection was successfully cured with antibiotics for a period ranging from 3 to 5 months. 2 patients were revised after the infection was cured for recurrent dislocation. No recurrent infection was found at the latest follow up.

One stage revision is gaining in popularity for the decreased morbidity and better quality of life of the patients. Weak points of one-stage revision are slightly inferior results in terms of eradication of the infection and the fact that it can be done only with cemented implants. Cemented implants show inferior durability than cementless implants and are difficult to remove if revision is needed. The use of a short cemented stem can couple the advantages of one stage revision and the fact that it is easily removed if this is needed for various reasons (aseptic loosening, recurrent dislocation and periprosthetic fracture). Contraindications to this technique are severe bone loss in the acetabulum or in the proximal femur.

The Olympia femoral stem is a stainless steel, anatomically shaped, polished and three-dimensionally tapered implant designed for use in cemented total hip arthroplasty (THA). The primary aim of this study was to determine the long-term survivorship, radiographic outcome, and patient reported outcome measures (PROMs) of the Olympia stem.

Between May 2003 and December 2005, 239 patients (264 THAs) underwent a THA with an Olympia stem in our institution. PROMs were assessed using the Oxford Hip Score (OHS), EuroQol-5 dimensions (EQ-5D) score and patient satisfaction at mean 10-years following THA. Patient records and radiographs were then reviewed at a mean of 16.5 years (SD 0.7, 15.3 to 17.8) following THA to identify occurrence of complications or revision surgery for any cause.

Mean patient age at surgery was 68.0 years (SD 10.9, 31–93 years). There were 156 women (65%, 176 THAs). Osteoarthritis was the indication for THA in 204 patients (85%). Stem survivorship at 10 years was 99.2% (95 % confidence interval [CI], 97.9%-100%) and at 15 years was 97.5% (94.6%–100%). The 15-year stem survival for aseptic loosening was 100%. Only one occurrence of peri-prosthetic fracture was identified, with no episodes of dislocation found. At a mean of 10 (SD 0.8, 8.7 –11.3) years follow-up, mean OHS was 39 (SD 10.3, range 7 – 48) and 94% of patients reported being very satisfied or satisfied.

The Olympia stem demonstrated excellent 10-year PROMs, very high rates of stem survivorship and negligible peri-prosthetic fracture and dislocation rate at final follow-up beyond 15 years.

Starting in 1977 a new cemented stem made of titanium alloy (with vanadium) was designed regarding some principle: rectangular shape, smooth surface covered with thin layer of titanium oxide, filling the medullar cavity. As a consequence: a thin layer of cement. It was designed with a collar. Initial Cementing technique used dough cement, vent tube and finger packing; then we applied cement retractor low viscosity cement and sometimes Harris Syringe. At the moment we went back to initial technique plus a cement retractor made of polyethylene. Many papers looked at long term follow up results depicting about 98 to 100 percent survivors at 10 years and 95 to 98% at 20 years (Hernigou, Hamadouche, Nizard, El Kaim).

Clinical as well as radiological results are available.

Radiological results depicted some radiolucent lines that appeared at the very long term. They could be related to friction between the stem and the cement. As advocated by Robin Ling, he called “French paradox” the fact that if a cemented prosthesis is smooth and fills the medullary cavity, long term excellent results could be expected.

This was the case with stainless steel Kerboull shape, the Ling design (Exeter)and the Ceraver design.

The majority of these stems were implanted with an all alumina bearing system. And in some occasion, when revision had to be performed, the stem was left in place (108 cases over 132 revisions)

Our experience over more than 5000 stems implanted is outstanding (see figure 1: aspect after 30 years).

Discussion other experience with cemented titanium stem were bad (Sarmiento, Fare). We suspect that this was related either to the small size of this flexible material, or to the roughness of its surface.

If one uses titanium cemented stem it must be large enough and extra smooth.

The triple taper polished cemented stem (C-stem, DePuy) was developed to promote calcar loading, and reduce proximal femoral bone resorption and aseptic loosening. We aimed to evaluate the changes in peri-prosthetic bone mineral density using Dual Energy X-ray Absorbtiometry (DEXA) after total hip arthroplasty (THA) using the C-stem prosthesis.

One hundred and three patients were recruited voluntarily through and single institution for THA. The prosthesis used was the triple-taper polished cemented C-Stem (De Puy, Warsaw, Indiana, USA). DEXA scans were performed pre- operatively, then at day for, three months, nine months, 18 months and 24 months post-operativley. Scans were analysed with specialised software (Lunar DPX) to measure bone mineral density (BMD) in all seven Gruen zones at each time interval. Changes in calcar BMD were also correlated with patient age, sex, surgical approach, pre-operative BMD and post-operative mobility to identify risk factors for periprosthetic bone resorption.

One hundred and three patients underwent 103 primary THA over a five-year period (98 osteoarthritis; 5 AVN). No femoral components were loose at the two year review and none were revised. The most marked bone resorption occured in Gruen zones 1 and 7, and was best preserved in zone 5. BMD decreased rapidly in all zones in the first three months post-operatively, after which the rate of decline slowed substantially. BMD was better preserved medially (zones 6 and 5) than laterally (zones 2 and 3) at 24 months. There was delayed recovery of BMD in all zones except zones 4 and 5.

High pre-operative T-scores (>2.0) in the spine, ipsilateral and contralateral femoral neck were associated with the higher post-operative BMD and less bone resorption at all time intervals in Gruen zone 7. Pre-operative osteopenia and osteoporosis were associated with low BMD and accelerated post-operative bone resorption in zone 7.

Patients whose mobility rendered them housebound had lower post-operative BMD, and accelerated post-operative BMD loss in zone 7 when compared to non-housebound patients. Females had a lower post-operative BMD and greater loss of BMD in zone 7. Patient age and surgical approach did not effect post-operative BMD or rate of bone resorption in zone 7.

The triple-taper femoral stem design did not show an increase in periprosthetic bone density at the proximal femur at two years post-operative. Calcar bone resorption is accelerated by low pre-operative BMD, poor post-operative mobility, and in females. Age and surgical approach do not have significant effects on calcar bone remodelling.

Introduction

The cement mantle thickness for cemented stem during total hip arthroplasty (THA) is different between the complete cement mantle technique and the line-to-line technique. In the line-to-line technique, the size of the rasp is same as that of the stem. We performed THA in321 hipsof 289 patientsusing a new designed triple-tapered polished cemented stem. We investigated the short-term result of these 321 hips clinically and radiographically.

Purpose: To assess the clinical and radiological performance of the Ultima THR.

Material-Methods: Between January 1991 and July 1994, 147 consecutive patients (154 hips) underwent a primary THR using an all-polyethylene cemented cup and the Ultima Ti alloy smooth, collarless, double tapered, straight stem. 65% were females and primary diagnosis was OA or RA in the majority. The average age at operation was 66.4 years. At average follow-up of 76 months, 34 patients (35 hips) were dead and 5 were lost. Patients were annually assessed clinically (HSS) and radiologically. Radiographs were digitized and migration analysis and cup wear was performed using the EBRA method.

Results: There were 9 aseptic failures (5 stems, 1 cup and 3 both components). Cup migration analysis was possible in 106 cases. Migration was detected in 62 of them (18 proximal, 15 medial, and 29 combined). Proximal migration ranged from 0.8 mm-4.0 mm and medial migration from 1.0 mm–3.5 mm. The average cumulative linear cup wear was 0.2 mm. Stem migration analysis was possible in 114 cases. At 2 years, 35 stems subsided less than 1.5 mm. Migration of more than 1.5 mm was observed in 16 stems. Early subsidence of more than 1.5 mm was highly predictive for later revision.

Conclusions: Ti-stems have been criticised for high failure rate but the exact mechanism of loosening is multifactorial. Our revision rate and the low incidence of focal osteolysis, even in the presence of a small degree of stem subsidence, indicate that a smooth double tapered Ti-alloy cemented stem may offer a durable long-term solution.

With an increasing number of primary total hip arthroplasties being carried out worldwide, and a lack or inadequate follow-up leading to delays in revision surgery, more complex problems including periprosthetic fracture have to be dealt with at revision surgery.

Unawareness, that clinical results do not reflect the mechanical state of the arthroplasty, together with strain shielding in the femur, progressive endosteal cavitation and stem migration may result in deterioration of the periprosthetic bone stock and femoral fracture.

Acute onset due to the fracture, severe symptoms and poor medical status of the patient usually demands immediate surgical intervention.

We have developed a modular cemented femoral component for revisions where deficiency of the proximal femur, or the femoral fracture, demands a variable extra-femoral portion of the stem. The shaft of the stem is 200mm or longer allowing the extra-medullary position to vary up to 15cm. It has a double polished taper

Between 1985 and 2007 the stem has been used in 79 revisions where there was a periprosthetic fracture. The mean age at surgery was 70 years (37–93) and the mean follow-up was 4 years (0–14 years 10 months). In 86% the primary surgery had been performed at another hospital. In 80% the fracture had united at one year. The main post-operative problem was dislocation in 10 cases between 7 days and 9 years after revision and was most common where the abductors were absent. 2 patients died in the post-operative period. Five hips have been re-revised, 3 for dislocation, 1 for Infection and 1 stem loosening.

Overall revision for periprosthetic fracture using this implant has given good results.

Although the results of this type of surgery are encouraging, this must not be considered as an alternative to regular follow-up and early intervention in cases where progressive loosening and deteriorating bone stock are likely to lead to a more demanding surgery.

Background

Method of fixation in THA is a contentious issue, with proponents of either technique citing improved implant survival and outcomes. Current comparisons rely on insufficiently powered studies with short-term follow up or larger poorly controlled registry studies. Patient factors are considered a key variable contributing to the risk of implant failure. One way to overcome this confounder is to compare the survival of cementless and cemented THAs patients who have undergone bilateral THAs with cemented hip on one side and cementless hip on the other. We compared stem survival of patients who have bilateral THA with one cemented stem in one hip and a cementless stem in the contralateral hip in the National Joint Registry.

Triple-tapered cemented polished C-Stem has evolved from the study of long-term results of the Charnley low-frictional torque arthroplasty when the first fractured stem and then proximal strain shielding of the femur and stem loosening were identified as the continuation of the same process: lack or loss of proximal stem support.

The C-Stem, by the concept, design and the surgical technique, caters for a limited slip of the stem within the cement mantle transferring the load more proximally. With a follow-up past 10 years and 3299 primary procedures there have been no revisions for aseptic stem loosening and no stem is radiologically loose.

Four hundred and forty eight patients had 500 LFAs using the C-Stem with the longest follow-up: 256 women and 192 men; 52 patients had bilateral LFAs. The patients’ mean age at surgery was 55.5 years (range 17–89 years) and at a mean follow-up of 5.2 years.

There was an overall improvement in the clinical outcome graded according to d’Aubigne and Postel for pain, function and movement from 3.1, 2.9 and 2.8 to 5.9, 5.7 and 5.5 respectively.

A good quality proximal femur had been maintained in 56.8% and improved in 21.8%.

The results are encouraging and support the concept but place a demand on the understanding of the technique and its execution at surgery.

Introduction:. The C-Stem in its design as a triple tapered stem, is the logical development of the original Charnley flat-back polished stem. The concept, design and the surgical technique cater for a limited slip of the stem within the cement mantle transferring the load more proximally.

Method: Five thousand two hundred and thirty three primary procedures using a C-stem have been carried out since 1993. We reviewed all 621 cases that had their total hip arthroplasty before 1998.

Results:. Sixty nine patients (70 hips) had died and 106 hips had not reached a ten-year clinical and radiological follow-up and had not been revised. In 22 hips, the stem had been changed before the 10 year follow-up, with infection, dislocation and loosening of the cup being the reasons for revision. None of the stems were loose.

The remaining 423 hips had a mean follow-up of 11 years (range 10 – 15 years). There were 216 women and 173 men, and 34 patients had bilateral LFAs. The patients’ mean age at surgery was 53 years (range 16 – 83 years). Thirty eight hips had been revised at the time of review. The reasons for revision were infection in 5: dislocation in 2: loose cup in 28: wear in 2 and 1 for meralgia paresthetica where the stem was found to be well fixed. In 1 case which had not been revised there was radiological loosening of the stem in a patient with Gaucher’s disease.

Discussion: With only 1 stem radiologically loose and no revisions for stem loosening the clinical results are very encouraging and they support the concept of the Charnley cemented low friction arthroplasty, but place a demand on the understanding of the technique and its execution at surgery.

Purpose: The original C-STEM (DePuy, Warsaw, IN, USA), a triple tapered polished collarless cemented stem, has an established clinical record. The new C-stem-AMT retains the identical intramedullary design, but enhances the extramedullary portion of the stem with a high offset option, and a mini-taper which is fully covered by the head, and accommodates a broad range of head diameters and neck lengths. This is an early report of clinical experience with the C-STEM AMT.

Methods: From March 2005 to June 2006, 34 C-STEMAMTs were implanted in 32 patients (21 females, 13 males) with mean age of 69 years (R 52–89). Diagnoses were Osteoarthritis in 30, AVN in 2, DDH in 1, and loose femoral implant in 1. Average follow-up was 9.7 months (R 3–18).

Preoperative and postoperative Harris Hip Scores, radiographs, and postoperative complications were recorded prospectively and compared to an early cohort of 66

C-Stems previously implanted between May 1999 and July 2001.

Results: Harris Hip Scores improved from 38 to 99 at one year. There has been no loosening, significant subsidence or reoperations. No dislocations have occurred, in contrast to 6 (9%) dislocations in the original C-Stem group.

Conclusions: As expected, the behaviour of the intramedullary portion of the C-Stem AMT is mirroring the experience with the C-Stem. The enhanced extramedullary design which accommodates additional neck lengths and head sizes, improves range of motion and provides additional offset has substantially reduced dislocation by facilitating accurate reconstruction of appropriate hip biomechanics.

Aims: We report 10-year results of the THR hybrid system. Femoral Component: Morscher-Spotorno MS-30¨, stainless steel, tapered, with- out collar with matte surface, þxed with Palakos¨+ Gentamycine bone cement. Cup: non-cemented Morscher Press-Fit Cup¨. Material and methods: A consecutive series of 123 THRs in 120 patients (75 female, 45 male) operated on between January 1990 and December 1992 were subjected to follow-up at 10 years. Mean age at surgery was 69 in women, 71 in men. No patients were lost to follow-up. 23 patients (19%) died without needing a revision, and 12 (10%) could only be inter- viewed by phone. Of the remaining 85 patients (71%) with 88 hips (70%) were available for complete evaluation. Mean follow-up was 9.8 (8.0 Ð 12.2 years).Results: Harris Hip scores were excellent and good in 84% (71 pts), moderate in 14% (12 pts) and poor in 2% (2 pts with rheumatoid arthritis). No stems or cups had to be revised. Radiographically 15 hips (13%) had femoral stem-related osteolyses Ð mostly in Gruen zones 2, 6 and 7. 8 stems subsided 2 Ð 5 mm. No infection and no acetabular osteolysis was observed. Conclusion: In 1990, the MS-30 stem was only available with a matte surface, which can impede settling and consequent maintenance of proximal load transfer to bone. Thus, although no revisions were necessary, the 13% osteolyses may relate to the matte surface. From 1994 on, the MS-30 stem has been available with a polished surface. The excellent outcome for the Morscher Press-Fit Cup corresponds to results in other series.

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

Purpose: In 1988, the conclusions of the SOFCOT symposium appear to condemn use of cemented implants for revision of loosened femoral elements. Eleven years later, at the 1999 Symposium, Vidalain demonstrated that cementing remains a reasonable alternative. The purpose of this retrospective analysis was to estimate long-term results of revisions using a long cemented stem without bone stock reconstruction.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent revision surgery with this technique. We retained for analysis 95 hips (15 lost to follow-up 25 deceased patients) in 66 women and 29 men, mean age 70 years at revision (42–86). The preoperative Postel Merle d’Aubigné (PMA) function score was 8/18. Femoral implants in place had been cemented in 80% of the hips. Using the SOFCOT criteria, 65% of the loosenings were stage II, 29.5% stage III. All were aseptic loosenings and the same revision technique was used in all cases: removal-replacement of both prosthetic elements, use of a long cemented stem without associated grafting.

Results: Mean follow-up was eight years (60–157). Thirty nine percent of the patients had early postoperative complications. The mean function score at last follow-up was 14.8/18 with 62.4% of the outcomes considered good or very good. Age, restitution of the rotation centre, quality of cementing, and stem/femur fit influenced the result significantly. Radiographic analysis showed a progressive lucent line in 32% of the hips, only 36% of the femoral stems were totally free of lucent lines. Cumulative actuarial survival was 87% at 14 years and fell to 65.5% considering certain radiographic loosening as the endpoint.

Conclusion: Use of a long cemented femoral stem for revision total hip arthroplasty provides acceptable long-term functional outcome. Results are significantly affected by imperfect technique. This type of implant, which destroys any hop for restoration of bone stock, should be reserved of elderly subject where a more “ambitious” procedure were be too risky.

Aims

To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications?