Total hip replacements (THRs) provide pain relief and improved function to thousands of patients suffering from end-stage osteoarthritis, every year. Over 800 different THR constructs were implanted in the UK in 2017. To ensure reliable implants are used, a NICE revision benchmark of 5% after 10 years exists. Given the 10-year cumulative mortality of patients under 55 years of age receiving THRs is only 5% and that a recent study suggests 25-year THR survival of 58%, we aim to produce revision estimates out to 30 years that may guide future long-term benchmarks.

The local database of the Princess Elizabeth Orthopaedic Centre (PEOC), Exeter, holds data on over 20,000 patients with nearly 30-years follow-up with contemporary prostheses. A previous study suggests that the results of this centre are generalisable if comparisons restricted to the same prostheses. Via flexible parametric survival analysis, we created an algorithm using this database, for revision of any part of the construct for any reason, controlling for age and gender. This algorithm was applied to 664,761 patients in the NJR who have undergone THR, producing a revision prediction for patients with the same prostheses as those used at this centre.

Using our algorithm, the 10-year predicted revision rate of THRs in the NJR was 2.2% (95% CI 1.8, 2.7) based on a 68-year-old female patient; well below the current NICE benchmark. Our predictions were validated by comparison to the maximum observed survival in the NJR (14.2 years) using restricted mean survival time (P=0.32). Our predicted cumulative revision estimate after 30 years is 6.5% (95% CI 4.5, 9.4). The low observed and predicted revision rate with the prosthesis combinations studied, suggest current benchmarks may be lowered and new ones introduced at 15 and 20 years to encourage the use of prostheses with high survival.

Aims

The aim of this study was to report the initial results of the Exeter V40 stem, which became available in 2000.

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We present a minimum 20-year follow-up study of 382 cemented Exeter Universal total hip arthroplasties (350 patients) operated on at a mean age of 66.3 years (17 to 94).

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This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices.

Introduction. The Exeter Hip femoral component remains largely unchanged from the original design, introduced in 1970. It is a highly polished, modular, double tapered stem and has undergone various minor modifications to surface, modularity and most recently the taper; changed to the current V40. TM. design in 2000. The effect of any design modification cannot easily be foreseen and greater emphasis is now placed on ensuring appropriate monitoring for such implants. Methods. We present the results of the first 540 V40. TM. Exeter THAs performed in our Centre between December 2000 and May 2002. All patients were reviewed prospectively at 1, 5 and 10 years following surgery. Results. Ten years after surgery there are no revisions for aseptic loosening and no evidence of aseptic loosening in any hip. The fate of every implant is known and all patients remain under review. One hundred and forty-five patients (26.9%) died before 10 years and of the remaining 395 stems, 374 (94.7%) remain in situ, 11 were revised (2.7%). Three were revised for infection, one for recurrent dislocation and one implant failed at the neck of the prosthesis. Ten were exchanged using cement-in-cement techniques to aid acetabular revision. There were ten periprosthetic fractures: six requiring stem revision, two underwent ORIF and two had already healed by the time the patients presented for follow-up. There was no radiographic evidence of failure preceding the periprosthetic fractures. All radiographs and pain scores were analysed as part of long-term follow-up, and are discussed. Discussion. There were no revisions for aseptic loosening. Previous studies from this centre reviewing the Original and Universal series have demonstrated the stem to provide a predictable and reproducible long term outcome with 100% survival well beyond10 years for aseptic loosening. Conclusion. The polished V40. TM. Exeter stem continues to perform well and survival has remained comparable to the Universal series

Introduction. Historical studies have reported incidences of taper corrosion in retrieved MoP hips of 20–50%. These studies relied on visual assessments, rather than using modern analytical techniques. Patients/Materials and Methods. The Northern Retrieval Registry was initiated to routinely analyse all retrieved hips. The volumetric wear rates of retrieved Exeter head tapers were measured using a coordinate measuring machine using validated methods and compared to the available results obtained from an ongoing study of failed MoM prostheses. Power analysis suggested that we would need at least fifty Exeter head tapers to provide significant results. Non-parametric tests were used to assess differences. We have previously identified head diameter/offset/taper angle and taper surface roughness as variables associated with taper wear. The effect of bearing material combination remains unquantified. These design variables were entered into a multiple regression model following log normalisation of taper wear. Results. 56 consecutively retrieved Exeter head tapers underwent assessment. 36 were of size 28mm. Primary causes for revision were acetabular loosening/periprosthetic fractures. Mean duration in vivo was 87 (1 – 252) months. Median total volumetric wear was 0.29mm. 3. with a wear rate of 0.07mm. 3. /year. There were 353 MoMs. Median taper wear rates for 28mm MoM was 0.07, for 36mm was 0.11, for 38–44mm was 0.31, for 45 – 48mm was 0.52, for 49–52 was 0.55mm and for >52mm was 1.36mm. 3. /year. While Exeter taper wear was significantly lower than the MoM group as a whole (p<0.001), regression modelling indicated that bearing diameter had the greatest influence on taper wear. Discussion. Contrary to previous literature reports, significant material loss at the taper junction of conventional arthroplasties is not commonly observed. Exeter hips appear to be protected to some extent by the smaller head size and lower taper roughness when compared to contemporary MoM devices. The effect of the bearing combination remains under investigation

We evaluated an operative technique, described by the Exeter Hip Unit, to assist accurate introduction of the femoral component. We assessed whether it led to a reduction in the rate of leg-length discrepancy after total hip arthroplasty (THA). A total of 100 patients undergoing THA were studied retrospectively; 50 were undertaken using the test method and 50 using conventional methods as a control group. The groups were matched with respect to patient demographics and the grade of surgeon. Three observers measured the depth of placement of the femoral component on post-operative radiographs and measured the length of the legs. There was a strong correlation between the depth of insertion of the femoral component and the templated depth in the test group (R = 0.92), suggesting accuracy of the technique. The mean leg-length discrepancy was 5.1 mm (0.6 to 21.4) pre-operatively and 1.3 mm (0.2 to 9.3) post-operatively. There was no difference between Consultants and Registrars as primary surgeons. Agreement between the templated and post-operative depth of insertion was associated with reduced post-operative leg-length discrepancy. The intra-class coefficient was R ≥ 0.88 for all measurements, indicating high observer agreement. The post-operative leg-length discrepancy was significantly lower in the test group (1.3 mm) compared with the control group (6.3 mm, p < 0.001). The Exeter technique is reproducible and leads to a lower incidence of leg-length discrepancy after THA. Cite this article: Bone Joint J 2015;97-B:154–9

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

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.

The Exeter femoral stem is a double-tapered highly polished collarless cemented implant with good long-term clinical results. In order to determine why the stem functions well we have undertaken a long-term radiostereometric analysis (RSA) study. A total of 20 patients undergoing primary Exeter total hip replacement for osteoarthritis using the Hardinge approach were recruited and followed with RSA for ten years. The stems progressively subsided and internally rotated with posterior head migration. The mean subsidence was 0.7 mm (95% confidence interval (CI) 0.5 to 0.9) at two years and 1.3 mm (95% CI 1.0 to 1.6) at ten years. The mean posterior migration of the head was 0.7 mm (95% CI 0.5 to 0.9) at two years and 1.2 mm (95% CI 1.0 to 1.4) at ten years. There was no significant cement restrictor migration. The Exeter stem continues to subside slowly into the cement mantle in the long term. This appears to compress the cement and the cement bone interface, contributing to secure fixation in the long term. Cite this article: Bone Joint J 2013;95-B:605–8

Aims

To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem.

We describe our experience with the implantation of 325 Exeter Universal hips. The fate of every implant was known. The procedures were undertaken by surgeons of widely differing experience. At follow-up at 12 years, survivorship with revision of the femoral component for aseptic loosening as the endpoint was 100% (95% CI 98 to 100). Survivorship with revision of the acetabular component for aseptic loosening as the endpoint was 96.86% (95% CI 93.1 to 98.9) and that with any reoperation as the endpoint 91.74% (95% CI 87.7 to 95.8). No adverse features have emerged as a consequence of the modular connection between the head and neck of the implant

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We report the incidence of radiolucent lines (RLLs) using two flanged acetabular components at total hip arthroplasty (THA) and the effect of the Rim Cutter.

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There are limited published data detailing the volumetric material loss from tapers of conventional metal-on-polyethylene (MoP) total hip arthroplasties (THAs). Our aim was to address this by comparing the taper wear rates measured in an explanted cohort of the widely used Exeter THA with those measured in a group of metal-on-metal (MoM) THAs.

Aims

We report on the outcome of the Exeter Contemporary flanged cemented all-polyethylene acetabular component with a mean follow-up of 12 years (10 to 13.9). This study reviewed 203 hips in 194 patients. 129 hips in 122 patients are still in situ; 66 hips in 64 patients were in patients who died before ten years, and eight hips (eight patients) were revised. Clinical outcome scores were available for 108 hips (104 patients) and radiographs for 103 hips (100 patients).

We report the outcome of the flangeless, cemented all-polyethylene Exeter acetabular component at a mean of 14.6 years (10 to 17) after operation. Of the 263 hips in 243 patients, 122 prostheses are still in situ; 112 patients (119 hips) have died, 18 hips have been revised, and three patients (four hips) were lost to follow-up. Radiographs at the final review were available for 110 of the 122 surviving hips. There were acetabular radiolucent lines in 54 hips (49%). Two acetabular components had migrated but neither patient required revision. The Kaplan-Meier survivorship at 15 years with 61 hips at risk with revision for any cause as the endpoint was 89.9% (95% confidence interval (CI) 84.6 to 95.2) and for aseptic loosening of the acetabular component or lysis 91.7% (95% CI 86.6 to 96.8). In 210 hips with a diagnosis of primary osteoarthritis, survivorship with revision for any cause as the endpoint was 93.2% (95% CI 88.1 to 98.3), and for aseptic loosening of the acetabular component 95.0% (95% CI 90.3 to 99.7).

The cemented all-polyethylene Exeter acetabular component has an excellent long-term survivorship.

We describe the survivorship of the Exeter femoral component in a District General Hospital. Between 1994 and 1996, 230 Exeter Universal cemented femoral components were implanted in 215 patients who were reviewed at a mean of 11.2 years (10 to 13). We used one acetabular implant, the Elite Ogee component, in 218 of the 230 hips.

During the period of this study 76 patients (79 hips) died. Of the remaining 139 patients (151 hips), 121 were able to attend for radiological analysis at a minimum of ten years. One patient was lost to follow-up.

No femoral component was revised for aseptic loosening. Three hips were revised for deep infection and six acetabular components required revision, four for loosening and two for recurrent dislocation. Taking the ‘worst-case scenario’ including the one patient lost to follow-up, the overall survival rate was 94.4% at 13 years.

Our results confirm excellent medium-term results for the Exeter Universal femoral component, implanted in a general setting. The excellent survival of this femoral component, when used in combination with the Ogee acetabular component, suggests that this is a successful pairing.

We reviewed 142 consecutive primary total hip replacements implanted into 123 patients between 1988 and 1993 using the Exeter Universal femoral stem. A total of 74 patients (88 hips) had survived for ten years or more and were reviewed at a mean of 12.7 years (10 to 17). There was no loss to follow-up.

The rate of revision of the femoral component for aseptic loosening and osteolysis was 1.1% (1 stem), that for revision for any cause was 2.2% (2 stems), and for re-operation for any cause was 21.6% (19 hips). Re-operation was because of failure of the acetabular component in all but two hips.

All but one femoral component subsided within the cement mantle to a mean of 1.52 mm (0 to 8.3) at the final follow-up. One further stem had subsided excessively (8 mm) and had lucent lines at the cement-stem and cement-bone interfaces. This was classified as a radiological failure and is awaiting revision. One stem was revised for deep infection and one for excessive peri-articular osteolysis. Defects of the cement mantle (Barrack grade C and D) were found in 28% of stems (25 hips), associated with increased subsidence (p = 0.01), but were not associated with endosteal lysis or failure.

Peri-articular osteolysis was significantly related to the degree of polyethylene wear (p < 0.001), which was in turn associated with a younger age (p = 0.01) and male gender (p < 0.001).

The use of the Exeter metal-backed acetabular component was a notable failure with 12 of 32 hips (37.5%) revised for loosening. The Harris-Galante components failed with excessive wear, osteolysis and dislocation with 15% revised (5 of 33 hips). Only one of 23 hips with a cemented Elite component (4%) was revised for loosening and osteolysis.

Our findings show that the Exeter Universal stem implanted outside the originating centre has excellent medium-term results.

Iontophoresis is a novel technique which may be used to facilitate the movement of antibiotics into the substance of bone using an electrical potential applied externally. We have examined the rate of early infection in allografts following application of this technique in clinical practice. A total of 31 patients undergoing revision arthroplasty or surgery for limb salvage received 34 iontophoresed sequential allografts, of which 26 survived for a minimum of two years. The mean serum antibiotic levels after operation were low (gentamicin 0.37 mg/l (0.2 to 0.5); flucloxacillin 1 mg/l (0 to 1) and the levels in the drains were high (gentamicin 40 mg/l (2.5 to 131); flucloxacillin 17 mg/l (1 to 43). There were no early deep infections. Two late infections were presumed to be haemotogenous; 28 of the 34 allografts were retained. In 12 patients with pre-existing proven infection further infection has not occurred at a mean follow-up of 51 months (24 to 82).