In 2006 the standard prosthesis for hip hemiarthroplasty in our unit was changed from the traditional Thompson prosthesis used for over 20 years to the monobloc Exeter Trauma Stem (ETS). The principle anticipated advantages were ease of stem implantation, improvement of orientation positioning and a consistency with modern proven femoral THR stem design. All patients selected for hemiarthroplasty replacement for a displaced subcapital fracture of the hip were eligible for inclusion. Failed previous surgical cases were excluded. The last 100 Thompson’s prostheses used before and the first 100 Exeter Trauma Stems undertaken after the changeover date were studied. Outcomes measured included surgical complications including infection, dislocation, fracture, necessity to ream etc. and technical adequacy of implant positioning based upon post-operative radiographs. Surgeon grade was recorded. There were no changes in surgical personnel. 206 consecutive patients were included in the study (age range 76–96); 67 men and 139 women. Data were collected prospectively as part of a comprehensive hip fracture audit. Initial results show that the rate of surgical complications is similar in both prosthesis groups. Radiographs demonstrate the presence of a learning curve in the use of the new prosthesis. On six occasions after December 2006 the Thompson prosthesis was used – this was due to unavailability of ETS prosthesis or where a very large femoral head (56mm) was required. The introduction of the ETS for hip hemiarthroplasty was successful. Initial conversion problems involved maintaining sufficient stock of the most commonly used size of prosthesis. Advantages were a low dislocation rate despite the greater potential for erroneous implant version and a reduction in the amount of femoral preparation required including reaming. Limitations of this study are the lack functional outcome and long term survivorship analysis

Recent guidance recommends the use of a well-proven cemented femoral stem for hemiarthroplasty in the management of fractures of the femoral neck, and the Exeter Trauma Stem (ETS) has been suggested as an example of such an implant. The design of this stem was based on the well-proven Exeter Total Hip Replacement stem (ETHRS). This study assessed the surface finish of the ETS in comparison with the ETHRS. Two ETSs and two ETHRSs were examined using a profilometer with a precision of 1 nm and compared with an explanted Exeter Matt stem. The mean roughness average (RA) of the ETSs was approximately ten times higher than that of the ETHRSs (0.235 μm (0.095 to 0.452) versus 0.025 μm (0.011 to 0.059); p < 0.001). The historical Exeter Matt stem roughness measured a mean RA of 0.973 μm (0.658 to 1.159). The change of the polished Exeter stem to a matt surface finish in 1976 resulted in a high stem failure rate. We do not yet know whether the surface differences between ETS and ETHRS will be clinically significant. We propose the inclusion of hemiarthroplasty stems in national joint registries. Cite this article: Bone Joint J 2013;95-B:173–6

Aims. Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty. Methods. Patients recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) between 1 September 1999 and 31 December 2020 who underwent hemiarthroplasty for the treatment of a hip fracture with the following implants were included: a cemented monoblock Exeter Trauma Stem (ETS), cemented Exeter V40 with a bipolar head, a monoblock Thompsons prosthesis (Cobalt/Chromium or Titanium), and an Exeter V40 with a Unitrax head. Overall and age-defined cumulative revision rates were compared over the ten years following surgery. Results. A total of 41,949 hemiarthroplasties were included. Exeter V40 with a Unitrax head was the most commonly used (n = 20,707, 49.4%). The overall rate of revision was small. A total of 28,201 patients (67.2%) were aged > 80 years. There were no significant differences in revision rates across all designs of hemiarthroplasty in patients of this age at any time. The revision rates for all designs were < 3.5%, three years postoperatively. At subsequent times the ETS and Exeter V40 with a bipolar head performed well in all age groups. The unadjusted ten-year mortality rate for the whole cohort was 82.2%. Conclusion. There was no difference in implant survival between all the designs of hemiarthroplasty in the first three years following surgery, supporting the selection of a cost-effective design of hemiarthroplasty for most patients with an intracapsular fracture of the hip, as determined by local availability and costs. Beyond this, the ETS and Exeter bipolar designs performed well in all age groups. Cite this article: Bone Joint J 2023;105-B(8):864–871

Implant choice was changed from cemented Thompson to Exeter Trauma Stem (ETS) for treatment of displaced intra-capsular neck of femur fractures in University Hospital Aintree, Liverpool, United Kingdom (a major trauma center), following the NICE guidelines that advised about the use of a proven femoral stem design rather than Austin Moore or Thompson stems for hemiarthroplasties. The aim of our study was to compare the results of Thompson versus ETS hemiarthroplasty in Aintree. We initially compared 100 Thompson hemiarthroplasties that were performed before the start of ETS use, with 100 ETS hemiarthroplasties. There was no statistically significant difference between the two groups in terms of patients' demographics (age, sex and ASA grade), intra-operative difficulties/complications, post op medical complications, blood transfusion, in-patient stay and dislocations. The operative time was statistically significantly longer in the ETS group (p= .0067). Worryingly, the 30 days mortality in ETS group was more than three times higher in ETS group (5 in Thompson group versus 16 in ETS group. P= .011). To corroborate our above findings we studied 100 more consecutive patients that had ETS hemiarthroplasty. The results of this group showed 30 day mortality of 8 percent. However the operative time was again significantly longer (p= .003) and there was 18 percent conversion to bipolar hemiarthropalsty. Moreover there was statistically significant increased rate of deep infection (7%, p = .03) and blood transfusion (27%, p = .007). This we feel may be due to longer and more surgically demanding operative technique including pressurised cementation in some patients with significant medical comorbidities. Our results raise the question whether ETS hemiarthoplasty implant is a good implant choice for neck of femur fracture patients. Randomised control trials are needed to prove that ETS implant is any better than Thompson hemiarthroplasty implants in this group of patients

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

The Exeter Trauma Stem (ETS) is a monoblock unipolar prosthesis currently in use throughout various orthopaedic departments. It can be a useful procedure for specialty trainees in developing modern cementation techniques in hip arthroplasty. We propose that in order for this procedure to be a valid training tool that, as well as having a standardized surgical approach and operative technique, outcomes should be easily assessed and should be similar if performed by either a trainee or consultant. All ETS procedures carried out at our institution from January 2009 until September 2011 were reviewed retrospectively. Patient demographics and operative details were recorded from patient notes. Radiographic evaluation involved the Barrack cementation grading system, Dorr's criteria, stem alignment and leg length measurement. There was no significant difference in operative time between ETS performed by consultant or by specialty trainee. On postoperative x-ray, cement mantles were Barrack grade A or B in 55.6% (trainees) versus 61.9% (consultants). Stem alignment was neutral in 50% and varus in 50% of cases for trainees, versus 28.6% and 71.4% of cases for consultants. In total, 69.2 % of patients had lengthening of the operated limb with a mean increase of 10.4mm (2–25) for trainees and 9.3mm (2–18) for consultants. Both trainees and consultants can attain a good cement mantle. However, from our results stem alignment is less accurate by trainees with half being placed in varus. Our results highlight the difficulty of obtaining correct leg length positioning with the ETS with trainees and consultants having similar discrepancies. The ETS is a useful procedure for orthopaedic trainees to attain adequate skills in modern cementation techniques with similar post-operative radiographic outcomes to consultants. The tendency for trainees to be less accurate with stem positioning could be improved with supervision or careful pre-operative templating

Osteoblastic cells response to mechanical forces by activating signal transduction cascades and altering gene expression patterns. We examined the responses of MC3T3E1 mouse osteoblasts to short term, low level (1000 microstrain, 1Hz) loads applied by cyclic deformation of the growth surface. At these load levels, daily short-term loading significantly retards the ascorbate induced differentiation of the cells as measured by alkaline phosphatase and osteopontin expression. This effect peaked at 5 minutes of loading per day; loads of 1 or more hours per day accelerated the differentiation process slightly as measured by the same criteria. C-fos is known to respond to mechanical loading of bones in vivo, we therefore examined the effect of brief loading bouts on c-fos promoter activity. Stable lines of MC3T3E1 cells carrying the fos promoter driving a luciferase reporter gene were loaded for 0, 5 or 60 minutes. For these experiments cells were grown in MEM without ascorbate and were then either supplemented or not with 37.5mM ascorbate-2-phosphate at confluence. In cells which had not been pre-treated with ascorbate the c-fos promoter was essentially unresponsive to loads. Following 24 hours of ascorbate treatment (placing these cells at the earliest stages differentiation) a 5 minute loading bout resulted in a marked (~ 50%) decrease in luciferase activity with a trough at 6–8 hours. Loading for 60 minutes caused a similar, but accelerated inhibition of luciferase activity with a trough at 2–4 hours after loading. 24 hours after loading, fos promoter activity had returned to baseline in cells loaded for 60 minutes but remained depressed at 75% of baseline in cells loaded for 5 minutes. Ets family transcription factors have been implicated in gene regulation in response to mechanical stimulation in several systems. The c-fos promoter contains a Serum Response Element which contains both a CarG motif responsible for binding the Serum Response Factor and an ets core motif CAGGT which can bind ets factors. We therefore repeated these experiments using a mutant c-fos promoter in which the ets binding site is destroyed. The response of this mutant to loading for 60 minutes was indistinguishable from that of the wt-promoter. However, in contrast to the wt-promoter, the ets-mutated promoter responded to a 5 minute loading with a rapid increase in activity (~150%) which peaked at 10 hours before returning to baseline at 24 hours. These results suggest that although similar in magnitude, the inhibition of the c-fos promoter by 5 and 60 minute loading bouts are regulated by different mechanisms, and implicate the ets family of transcription factors in the response to the briefer loading events

Introduction and Aims: Matrix metalloproteinases can contribute to the processes of tumor invasion and metastasis. One proposed mechanism that could augment MMP-1 expression in individual patients is the existence of an Ets transcription factor-binding site in the MMP-1 promoter sequence. The aim of our study was to identify the prevalence of this single nucleotide polymorphism in chondrosarcoma patients and investigate its impact on disease outcome. Method: Sixty-seven chondrosarcoma specimens were selected from an established tumor bank. DNA was extracted, amplified with polymerase chain reaction, and sequenced to determine the proportion of genotypes demonstrating the presence (GG) or absence (G) of the SNP at the base pair of interest. The presence of the Ets binding site was correlated with disease-free survival. Results: Eighteen (27%) samples were G/G homozygous for absence of the Ets site, 34 (51%) were G/GG heterozygous for the SNP, and 15 (22%) were GG/GG homozygous for the SNP. The five-year overall survival rate for patients with the G/G homozygote was 78%, compared with 80% and 84% in patients with the G/GG heterozygotes and GG/GG homozygotes, respectively (p=0.5527). The disease-free survival rate of patients with the G/G genotype were 34%, compared with 74% and 100% in patients with the G/GG and GG/GG genotypes, respectively (p=0.0365). Conclusion: The disease-free survival in patients having a GG allele was statistically better than the G allele. The observed correlation between the presence of the Ets binding site and better prognosis suggests a down-regulation of MMP-1 expression

Ewing sarcoma (ES) is an aggressive sarcoma, and is the second most common bone sarcoma in childhood. Disease specific t(11;22)(~85–90%), t(21;22)(~5–10%), or rarer variant translocations with the involvement of chromosome 22 (~5%) are present. At the gene level, the EWSR1 gene fuses with FLI1, ERG or other ETS transcription factor family members. So far, no ES has been identified with a fusion to transcription factors other than ETS. By using a panel of molecular tools such as multicolor FISH and array-CGH, a ring chromosome containing chromosomes 20 and 22 was identified in four ES cases. Molecular karyotyping showed the translocation and amplification of regions of chromosomes 20q13 and 22q12. Cloning of the breakpoint showed an in-frame fusion between the EWSR1 and NFATc2 genes. The translocation led to the loss of the N-terminal, calcineurin-dependent control region. Consequently, the remaining intact DNA binding domain of NFATc2 is under control of the EWSR1 promoter region permitting oncogenic activation. Intriguingly, in all cases a distinct histological feature was observed. In conclusion: a new translocation involving EWS and NFATc2 was cloned that is associated with a histological variant of ES. The NFATc2 transcription factor is not a member of the ETS family of transcription factors. NFTAC2 has well characterized functions in T-cell differentiation and immune response. For the first time a direct involvement of NFATc2 in oncogenesis has been shown

Background. Exeter Trauma Stem (ETS) is a polished tapered collarless monopolar prosthesis used for cemented hemiarthroplasty for fracture neck of femur. Two modular rasps are available on the instrumentation set. The larger rasp, in practice, rarely fits into the femur making trial reduction impossible. Our hypothesis was that the absence of a trial reduction could affect leg length and stability of the prosthesis. Aim. To evaluate the leg length discrepancy following use of Exeter Trauma Stem for intracapsular fracture neck of femur. Methods. All patients who underwent ETS hemiarthroplasty between June 2009 to March 2010 (n = 100) were included in the study. Radiographic assessment of leg length was performed by two independent assessors based on measurements by Woolson et al. Results. Upto half of the patients had equal leg length measurements. Forty four patients had lengthening of the operated leg with a mean of 10mm (5–25). Further complications included four dislocations. There was no statistical significance between leg lengths and dislocations. Conclusion. Care is needed with regards to correct positioning of the ETS prosthesis to achieve equal leg lengths. Following this study a new intermediate sized modular rasp has been introduced to the instrumentation set

Exeter Trauma Stem (ETS) is one of the most common implants used for treating displaced intracapsular hip fractures in the UK. We previously performed a radiographic audit of these implants which showed good placement was difficult. This was in particular relation to leg length discrepancy (LLD). This study reviewed the clinical outcomes of these patients, in particular looking at the relation of leg length discrepancy to outcome. We performed a clinical review of patients at 3 months and 1 year post ETS for hip fracture. Oxford hip score (OHS), Trendelenberg test, Visual Analogue Score (VAS) and walking aids required were recorded. Leg length discrepancy was determined radiographically on initial post op X-ray. This was recorded as Even (+/− 5mm), 6-10mm Long and >10mm long. Seventy-two patients were reviewed at 3 months and 21 at 1 year. Mean VAS was 1.6. At 3 months 66% were Trendelenberg positive. Of those Trendelenberg positive at 3 months only 42% remained positive at 1 year. Mean OHS at 3months and 1 year was 30.8 and 32.1 respectively. On radiographic review 38 implants were Even, 24 were 6-10mm Long and 10 implants were >10mm Long. There was no correlation between leg length discrepancy and either VAS or Trendelenberg test. 45 patients ambulated independently pre-op. Of these only 8 ambulated independently post-op, 18 used a stick and 11 a Zimmer frame. There was no correlation between post operative leg length discrepancy and either Visual Analogue Score, OHS or Trendelenberg test. Mean pain score was very low. There was however almost 10% of patients with a VAS greater than 6. 80% of patients dropped one ambulatory level post-op, this is consistent with previous studies. The ETS provides good pain relief with a low complication rate in the vast majority of patients

Introduction. Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital. Methods. We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death. Results. Over a 64 month period 15 cases were identified. Peri-operative death (PAD) was 1% (15/1402). 4/15 patients died intra-operatively. PAD was highest following Exeter Trauma Stem (ETS) implantation (5/85, 6%) and nil following Bipolar arthroplasty, Austin-Moore arthroplasty (AMA) or Cannulated screw fixation. PAD following total hip arthroplasty was 4% (1/25), Thompson's hemi-arthroplasty 2% (3/191), and Dynamic Hip Screw fixation 1% (6/695). Overall mortality after cemented implant was 2%. ETS implantation led to significantly increased peri-operative mortality compared to AMA (p=0.004). Operations were performed by both trainees (12) and Consultants (3). Both trainees (9) and Consultants (6) anaesthetised the patients. None of the patients belonged to ASA I or II (ASA III 6 and IV 9). All patients had significant cardio-vascular or pulmonary co-morbidity (Ca Lung 2, pulmonary fibrosis 1, end stage COAD 1, AF 6). Cemented implant insertion was followed by immediate haemodynamic collapse and death in 4/15, intra-operative haemodynamic instability in 1/15 and peri-operative instability in 5/15. Post-mortem was performed in 5/15: 2/5 were Pulmonary Embolism (PE), 2/5 bronchopneumonia and 1/5 Myocardial infarction (MI). 4/15 had suspected MI and 1/15 suspected PE. Conclusion. There was 1% risk of peri-operative death after hip fracture surgery. This risk was increased following cemented hemiarthroplasty and highest after ETS implantation. Risk was exacerbated in patients with pre-existing cardiovascular morbidity and independent of the seniority of the surgeon or the anaesthetist

Recent NICE guidelines have suggested abandoning the Thompson hemiarthroplasty (TH) in favour of a ‘proven prosthesis’ such as the Exeter Trauma Stem (ETS). This is controversial because of significant cost implications and limited research assessing outcomes of the ETS. The aim of this study was to assess the treatment of intracapsular neck of femur fractures with the TH. Between 2002 and 2006 (minimum 5 year follow-up), 431 cemented TH's were performed. Death rate at 1 year and 5 years were 26.0% and 67.7% respectively. Dislocation (1.4%) and infection (0.2%) rates were low and revision rate was 1.2%. Comparison was made to Bipolar hemiarthroplasties over the same period (total 194). These had lower rates of dislocation (0.5%) and infection (0.5%) with a significantly higher (3.6%) revision rate. We feel that the TH remains the current gold standard treatment for intracapsular fractures, in appropriate patients, due to low complication and revision rates. Modern implants may provide better function or longevity, but there is no evidence in the literature to support abandoning the TH. Surgeons should assess patients and decide on its use, despite NICE guidelines, as it remains a cost effective treatment method, particularly for older, less mobile and cognitively impaired patients

To determine if any notable differences between a cemented Thompson stem hemiarthroplasty and a cemented Exeter stem hemiarthroplasty (ETS), 200 patients with a displaced intracapsular fracture were randomised between the two prosthesis. Surviving patients were followed-up for one year by a nurse blinded to the treatment allocation. The mean age of patients was 84 years and 13% were male. There were no differences between groups for the length of surgery, need for blood transfusion or hospital stay. Implant related complications were three minor operative fractures of the femur in each group. Two patients in the Thompson group had dislocation of the prosthesis requiring revision surgery and one further patient in the Thompson group had late acetabular wear requiring conversion to a total hip replacement. One further patient in the Thompson group had cement retained in the acetabulum. In total therefore only three patients, all in the Thompson group, which required revision surgery. Easy of surgery was assessed subjectively by the surgeon and reported to be easier for the ETS group (p=0.0002). During follow-up there was no significant difference in the degree of residual pain between groups. Conclusions are that the cemented Exeter stem hemiarthroplasty has some advantages over the traditional cemented Thompson hemiarthroplasty

Ewing Tumors (ET) are highly malignant, localized in bone or soft tissue and are molecularly defined by ews/ets translocations. DNA microarray analysis revealed a relationship of ET to both endothelium and fetal neural crest. We identified expression of histone methyl-transferase Enhancer of Zeste, Drosophila, Homolog 2 (EZH2) to be increased in ET. EZH2’s suppressive activity maintains stemness in normal and malignant cells. Here, we found EWS/FLI1 bound to the EZH2 promoter in vivo and induced EZH2 expression in ET and mesenchymal stem cells. Down-regulation of EZH2 by RNA interference in ET suppressed oncogenic transformation by inhibiting clonogenicity in vitro. Similarly, tumor development and metastasis was suppressed in immunodeficient Rag2−/−γC−/− mice. EZH2-mediated gene silencing was shown to be dependent on histone deacetylase (HDAC) activity. Subsequent microarray analysis of EZH2 knock down, HDAC-inhibitor treatment and confirmation in independent assays revealed an undifferentiated phenotype maintained by EZH2 in ET. EZH2 regulated stemness genes such as nerve growth factor receptor (NGFR) as well as genes involved in neuroectodermal and endothelial differentiation (EMP1, EPHB2, GFAP, GAP43). These data suggest that EZH2 might play a central role in Ewing Tumor pathology by shaping the oncogenicity and stem cell phenotype of this tumor

Introduction: A Health Action Zone project has been designed to assess the effect of a public education programme to improve the community awareness of the correct approach to low back pain. As part of this project a preliminary survey of the public has been undertaken. Methods: 195 members of the public were surveyed using by a number of members of the team using a pro-forma. Interview sites were selected to provide a cross section of the population of the community. Demographic details were collected together with data related to low back pain prevalence and attitudes to self management. Discussion: The initial survey shows that people take too much rest and do too little exercise. The HAZ projects, which have been in existence for three years, have had small penetrance into the community. The Teesside Back Pain Partnership so far has focussed on individual education as part of other strategies. A radio, bus posters, leaf ets and posters campaign aimed at changing beliefs on back pain management. the pattern of behaviour is planned. The extremely low level of awareness of the TBPP will provide an opportunity to measure how much of any change may be attributed to this campaign

Objectives

The objective of this study was to assess all evidence comparing the Thompson monoblock hemiarthroplasty with modular unipolar implants for patients requiring hemiarthroplasty of the hip with respect to mortality and complications.

A total of 56 male patients with a displaced intracapsular fracture of the hip and a mean age of 81 years (62 to 94), were randomised to be treated with either a cemented hemiarthroplasty (the Exeter Trauma Stem) or reduction and internal fixation using the Targon Femoral Plate. All surviving patients were reviewed one year after the injury, at which time restoration of function and pain in the hip was assessed. There was no statistically significant difference in mortality between the two groups (7/26; 26.9% for hemiarthroplasty vs 10/30; 33.3% for internal fixation). No patient treated with a hemiarthroplasty required further surgery, but eight patients treated by internal fixation did (p = 0.005), five requiring hemiarthroplasty and three requiring total hip arthroplasty. Those treated by internal fixation had significantly more pain (p = 0.02). The restoration of mobility and independence were similar in the two groups.

These results indicate that cemented hemiarthroplasty gives better results than internal fixation in elderly men with a displaced intracapsular fracture of the hip.

Cite this article: Bone Joint J 2015;97-B:992–6.