Method. 286 patients underwent total hip arthroplasty with a cemented titanium femoral implant (Ultima, Johnson & Johnson) between July 1995 and July 2001. The acetabular component was either a porous coated cup or a cemented all-polyethylene cup. A 28mm cobalt chromium head was used in all patients. Patients were prospectively evaluated with clinical examination, Harris hip scores and radiographic assessment. Analysis of the data was performed. Results. Of the 286 patients, 11 patients were excluded from analysis for reasons including incomplete data (8) and death (3). The remaining 275 patients were comprised of 118 males and 157 females with an average age of 70.8 years (55–89 years). The average follow up was 10.5 years (1.03–14.23). The median follow up was 10 years. 177 cemented all-polyethylene and 98 porous coated acetabular cups were used. The average Harris hip scores were 34.4 and 81.25 for preoperative and last follow up visit respectively. 11 stems were revised (aseptic loosening 9, infection 2). Radiographic assessment showed vertical subsidence in 30 patients (10.9%) (>5mm in 6 and < 5mm in 24 patients). Complete cement-bone radiolucency was noted in 11 stems (4%). Radiolucent lines covering < 50% of cement-bone interface were noted in 18 stems (6.5%). There were no cases of cement fracture. Kaplan-Meier survivorship was 91% at 10 years & 89.8% at 12 years. Conclusions. This prospective study represents the largest reported cohort of patients with a cemented titanium alloy femoral stem. The long term clinical outcome of this stem is similar to that reported in other studies, but not equivalent to collarless polished tapered or modern uncemented stems. Radiographic loosening of these stems is similar to other studies in the current literature. Long-term follow-up is required to identify patients at risk of needing revision, and our institution no longer uses this implant

ZrN-multilayer coating is clinically well established in total knee arthroplasty [1-3] and has demonstrated significant reduction in polyethylene wear and metal ion release [4,5]. The goal of our study was to analyze the biotribological behaviour of the ZrN-multilayer coating on a polished cobalt-chromium cemented hip stem. CoCr28Mo6 alloy hip stems with ZrN-multilayer coating (CoreHip®AS) were tested versus an un-coated version. In a worst-case-scenario the stems with ceramic heads have been tested in bovine serum in a severe cement interface debonding condition under a cyclic load of 3,875 N for 15 million cycles. After 1, 3, 5, 10 & 15 million cycles the surface texture was analysed by scanning-electron-microscopy (SEM) and energy-dispersive x-ray (EDX). Metal ion concentration of Co,Cr,Mo was measured by inductively coupled plasma mass spectroscopy (ICP-MS) after each test interval. Based on SEM/EDX analysis, it has been demonstrated that the ZrN-multilayer coating keeps his integrity over 15 million cycles of severe stem cemented interface debonding without any exposure of the CoCr28Mo6 substrate. The ZrN-multilayer coated polished cobalt-chromium cemented hip stem has shown a reduction of Co & Cr metal ion release by two orders of a magnitude, even under severe stem debonding and high interface micro-motion conditions. ZrN-multilayer coating on polished cobalt-chromium cemented hip stems might be a suitable option for further minimisation of Co & Cr metal ion release in total hip arthroplasty. Clinical evidence has to be proven during the next years

Dual mobility (DM) is an established bearing option in Total Hip Arthroplasty (THA). The traditional mono-block DM designs have limited ability for additional fixation, whereas the modular DM designs allow additional screw fixation but limit internal diameter and have the potential to generate metal debris. We report the early results of a CoCrMo alloy mono-block implant manufactured by additive technology with a highly porous ingrowth surface to enhance primary fixation and osseointegration. Prospective follow-up of the Duplex. TM. implant first inserted in March 2016 enrolled into Beyond Compliance (BC). Primary outcome measure was all-cause revision and secondary outcomes dislocation, peri-prosthetic fracture (PPF) and Oxford Hip Score (OHS). Patients were risk stratified and all considered to be high risk for instability. Complications were identified via hospital records, clinical coding linkage using national database and via BC website. 159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a cemented Polished taper stem (PTS) had a Type B PPF rate of 2.1% requiring revision/fixation. Compared to conventional THA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool. We believe our results demonstrate that risk stratification successfully aids implant selection to prevent dislocation in high-risk patients. This novel design has provided excellent early results in a challenging cohort where individuals are very different to the “average” THA patient. NJR data on DM has reported an increase in revision for PPF. A “perfect storm” maybe created using DM in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection

Durable humeral component fixation in shoulder arthroplasty is necessary to prevent painful aseptic loosening and resultant humeral bone loss. Causes of humeral component loosening include stem design and material, stem length and geometry, ingrowth vs. ongrowth surfaces, quality of bone available for fixation, glenoid polyethylene debris osteolysis, exclusion of articular particulate debris, joint stability, rotator cuff function, and patient activity levels. Fixation of the humeral component may be achieved by cement fixation either partial or complete and press-fit fixation. During the past two decades, uncemented humeral fixation has become more popular, especially with short stems and stemless press fit designs. Cemented humeral component fixation risks difficult and complicated revision surgery, stress shielding of the tuberosities and humeral shaft periprosthetic fractures at the junction of the stiff cemented stem and the remaining humeral shaft. Press fit fixation may minimise these cemented risks but has potential for stem loosening. A randomised clinical trial of 161 patients with cemented vs. press fit anatomic total shoulder replacements found that cemented fixation of the humeral component provided better quality of life, strength, and range of motion than uncemented fixation but longer operative times. Another study found increased humeral osteolysis (43%) associated with glenoid component loosening and polyethylene wear, while stress shielding was seen with well-fixed press fit humeral components. During reverse replacement the biomechanical forces are different on the humeral stem. Stem loosening during reverse replacement may have different factors than anatomic replacement. A systemic review of 41 reverse arthroplasty clinical studies compared the functional outcomes and complications of cemented and uncemented stems in approximately 1800 patients. There was no difference in the risk of stem loosening or revision between cemented and uncemented stems. Uncemented stems have at least equivalent clinical and radiographic outcomes compared with cemented stems during reverse shoulder arthroplasty. Durable humeral component fixation in shoulder arthroplasty is associated with fully cemented stems or well ingrown components that exclude potential synovial debris that may cause osteolysis

Constrained implants with intra-medullary fixation are expedient for complex TKA. Constraint is associated with loosening, but can correction of deformity mitigate risk of loosening?. Primary TKA's with a non-linked constrained prosthesis from 2010-2018 were identified. Indications were ligamentous instability or intra-medullary fixation to bypass stress risers. All included fully cemented 30mm stem extensions on tibia and femur. If soft tissue stability was achieved, a posterior stabilized (PS) tibial insert was selected. Pre and post TKA full length radiographs showed. i. hip-knee-ankle angles (HKAA). ii. Kennedy Zone (KZ) where hip to ankle vector crosses knee joint. 77 TKA's in 68 patients, average age 69.3 years (41-89.5) with OA (65%) post-trauma (24.5%) and inflammatory arthropathy (10.5%). Pre-op radiographs (62 knees) showed varus in 37.0%. (HKAA: 4. o. -29. o. ), valgus in 59.6% (HKAA range 8. o. -41. o. ) and 2 knees in neutral. 13 cases deceased within 2 years were excluded. Six with 2 year follow up pending have not been revised. Mean follow-up is 6.1 yrs (2.4-11.9yrs). Long post-op radiographs showed 34 (57.6%) in central KZ (HKKA 180. o. +/- 2. o. ). . Thirteen (22.0%) were in mechanical varus (HKAA 3. o. -15. o. ) and 12 (20.3%) in mechanical valgus: HKAA (171. o. -178. o. ). Three failed with infection; 2 after ORIF and one with BMI>50. The greatest post op varus suffered peri-prosthetic fracture. There was no aseptic loosening or instability. Only full-length radiographs accurately measure alignment and very few similar studies exist. No cases failed by loosening or instability, but PPF followed persistent malalignment. Infection complicated prior ORIF and elevated BMI. This does not endorse indiscriminate use of mechanically constrained knee prostheses. Lower demand patients with complex arthropathy, especially severe deformity, benefit from fully cemented, non-linked constrained prostheses, with intra-medullary fixation. Hinges are not necessarily indicated, and rotational constraint does not lead to loosening

Purpose. The purpose of this study is to evaluate the clinical outcomes and and radiological findings of primary total hip arthroplasty(THA) performed by using cemented polished femoral stem. Materials and Methods. We retrospectively reviewed 91 hips (84 patients) that had undergone primary THA with cemented polished femoral stem after follow-up more than 10 years. The mean age at surgery was 57 years old (47 to 75). Mean follow up period was 12. 8 years(10.1 to 14). Clinical evaluation was performed using Harris hip score. The radiographic evaluation was performed in terms of the cementing technique, including of subsidence within the cement mantle, radiolucent lines at the cement-bone or cement-stem interface, cortical hypertrophy, and calcar resorption. Results. At the final follow-up, mean Harris hip score had improved from 55.2 points to 93.2 points. Barrack classification was 50 cases in A grade, 32 cases in B grade, 9 cases in C grade. Except only one case, subsidence of femoral stem was observed less than 2mm. There were no progressing radiolucent line and loosening of femoral stem. Conclusion. Our results in this study show good outcome for cemented polished femoral stem at follow-up more than 10 years

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant. A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed. Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17–86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1). These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant. A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed. Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17-86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1). These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed

The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different. In the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group. Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success. The author's personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups. The author's current indication for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection. Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component. The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is an extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000. A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems, unfortunately, may continue to go down as it is uncommonly taught in residency and fellowship, however, it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons armamentarium when treating patients undergoing primary and revision THA

Introduction. Metal ion and particle release, particularly cobalt, has become an important subject in total hip arthroplasty, as it has shown to induce metal hypersensitivity, adverse local tissue reactions and systemic ion related diseases. The purpose of the following study was compare the ion release barrier function of a zirconium nitride (ZrN) multilayer coated hip stem for cemented use, designed for patients with metal ion hypersensitivity, against its uncoated version in a test configuration simulating the worst case scenario of a severely debonded hip stem. The ZrN multilayer coating is applied on a CoCrMo hip stem and consists of a thin adhesive chromium layer, five alternating intermediate layers out of chromium nitride (CrN) and chromium carbonitride (CrCN) and a final zirconium nitride (ZrN) shielding layer [1]. Methods. Hip stems with a ZrN multilayer coating (CoreHip AS, Aesculap AG, Germany) were tested in comparison with a cobalt-chrome uncoated version (CoreHip, Aesculap AG, Germany). In order to create a worst case scenario, the smallest stem size with the biggest offset in combination with an XL ceramic head (offset +7 mm) was used. The stems were embedded according to the ISO 7206-6 test in a bone cement sheet. Once the bone cement was bonded, the stem was pulled out and a PMMA grain was placed inside the femoral cavity in order to uprise the hip stem above its embedding line and simulate a debonded cemented hip stem with a severe toggling condition. The dynamic test was performed under bovine serum environment with an axial force of 3.875 kN [2] at 11.6 Hz for 15 million cycles. The test was interrupted after 1, 3, 5, 10 and 15 million cycles and the surfaces of the stems were analyzed through scanning electron microscopy (SEM) with energy dispersive X-Ray (EDX). Moreover, the test medium was analyzed for metal ion concentration (cobalt, chromium and molybdenum) using ICP-MS. Results. The SEM/EDX analysis demonstrated that the ZrN multilayer coating kept its integrity, as no trace of the substrate material (CoCrMo) could be detected. Furthermore, the taper of the ZrN group showed less fretting and corrosion than the taper of the CoCrMo stem (Fig.1). Moreover, the ion concentration analysis showed a reduction of up to two orders of magnitude in the release of cobalt, chromium and molybdenum in the ZrN coated stems in comparison with the uncoated version. Discussion. The results showed that, even in a worst case scenario of high micro-motion due to a severe stem debonding within the cement mantle, the hip stems with a ZrN multilayer coating substantially reduce the release of ions from the substrate material. For any figures or tables, please contact the authors directly

Revision of the humeral component in shoulder arthroplasty is frequently necessary during revision surgery. Newer devices have been developed that allow for easy extraction or conversion at the time of revision preserving bone stock and simplifying the procedure. However, early generation anatomic and reverse humeral stems were frequently cemented into place. Monoblock or fixed collar stems make accessing the canal from above challenging. The cortex of the Humerus is far thinner than the femur and stress shielding has commonly led to osteopenia. Many stem designs have fins that project into the tuberosities putting them at risk for fracture on extraction. Extraction starts with an extended deltopectoral incision from the clavicle to the deltoid insertion. The proximal humerus needs to be freed from adhesions of the deltoid and conjoined tendon. The deltopectoral interval is fully developed. Complete subscapularis and anterior capsular release to the level of the latissimus tendon permits full exposure of the humeral head. After head removal the stem can be assessed for loosening and signs of periprosthetic joint infection. The proximal bone around the fin of the implant should be removed from the canal. If possible, the manufacturer's extractor should be utilised. If not, then a blunt impactor can be placed from below against the collar of the stem to assist in extraction. With luck the stem can be extracted from the cement mantle. If there is no concern for infection, the cement-in-cement technique can be used for revision. Otherwise, attempts should be made to extract all the cement and cement restrictor, if present. The small cement removal tools from the hip set can be used and specialised shoulder tools are available. An ultrasound cement removal device can be very helpful. The surgeon must be particularly careful to avoid perforation of the humeral cortex. This is especially important when near the radial nerve as injury can occur. When a well-fixed stem is encountered, an osteotomy of the proximal humerus is necessary. The surgeon can utilise a linear cut with an oscillating saw along the bicipital groove for the length of the implant. An osteotome is used to crack the cement mantle allowing stem extraction. Alternatively, a window can be created to offer additional access to the cement mantle. In the event the surgeon has required an osteotomy or window, cerclage wires, cables or suture will be needed and when the bone is potentially compromised, allograft bone graft struts (tibial shaft) are used for additional support. Care is needed when passing cerclage wires to avoid injury to the radial nerve which is adjacent to the deltoid insertion. If infection is suspected or confirmed an ALBC spacer is placed. When single stage revision is planned both cemented and uncemented stem options are available. Cement placed around the humeral stem has been suggested to decrease infection incidence. Revision of cemented humeral stems is a continued challenge in revision shoulder surgery. Newer systems and reverse total shoulder options have improved the surgeon's ability to achieve good outcomes when revising prior shoulder arthroplasty

Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30 to 150 microinches. Results. Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results and Kaplan-Meier survivorship ranges from 90% to 99.5% in the best case scenario were noted at 10 to 20 year follow-up. Conclusion. With a properly-designed femoral stem, good cement technique, proper cement mantle, and surface roughness of 30 to 40 microinches, the cemented femoral stem provides a durable hip replacement in patients 60 to 80 years old with up to 95% survivorship at 10 to 20 year follow-up

Following the recommendation of NICE guidelines (CG124) we have recently started using cemented smooth tapered stem hemiarthroplasty as our standard management of intra-capsular neck of femur fractures. Prior to publication of the above guidelines the standard implant utilised was Thompson Hemiarthroplasty prosthesis. The cost implications of this change have not been fully appreciated and the benefit of these changes in ASA grade 3–4 patients has not previously been analysed. We identified a cohort of 89 patients admitted with displaced intra-capsular neck of femur fracture with an ASA grade 3–4. These underwent hip hemiarthroplaties at our centre over a period of 12 months (before and after guideline implementation). Data regarding in-hospital mortality, dislocation, reoperation and place of discharge were retrospectively collected and analysed. Our cohort included 46 patients who underwent a Thompsons Hemiarthroplasty, 30 patients who had a cemented smooth tapered stem hemiarthroplasty and 13 patients who had an Austin-moore Hemiarthroplasty. In-patient mortality rates were highest in the Austin-moore group, followed by the Thompsons group compared to none in the smooth tapered stem group. However, this was not statistically significant. One patient in the Thompsons group and one patient in the smooth tapered group had multiple dislocations and re-operations, compared with none in the Austin-moore group. In terms of percentage of patients who were discharged home from hospital the smooth tapered stem group had a percentage that was more than twice that of the Thompson's which was in turn higher than that found in the Austin-moore group. In conclusion, our data suggests that in patients with an ASA grade of 3–4 there is no significant benefit from using cemented smooth tapper stems when performing a Hip Hemiarthroplasty compared with a well performed Thompsons and that the cost savings of this is significant. We accept that our current numbers are relatively small and further work is needed

Periprosthetic joint infection (PJI) is one of the most feared complications following total knee arthroplasty (TKA). Despite improved peri-operative antibiotic management and local antibiotic-loaded bone cement PJI is reported in about 0.5–1.9 % of primary knee replacement. In case of revision knee arthroplasty the infection rate even occurs at about 8–10 %. Depending on an acute or late PJI several surgical methods are used to treat the infection. However, suffering of a late PJI, the only surgical procedure remains the exchange of the TKA in combination with a radical debridement and removal of all foreign material. In order to achieve complete debridement of the joint, the soft tissue must be radically excised. Frequently, the debridement of the posterior capsule causes severe difficulties, therefore it might be necessary to resect the collateral ligaments to be able to reach the posterior parts of the capsule. But this necessitates the use of a higher level of constraint such as a rotating or total hinge and fully cemented long stemmed revision implants. Furthermore, due to the cemented stems, a sufficient amount of antibiotic-loaded cement may be delivered to the bone as topical therapy. Up to now, several studies have shown excellent functional long-term results for hinge knee prostheses after PJI and a very good infection control rate. Advantages of the hinge knee prosthesis in cases of PJI are the opportunity for a complete debridement especially while addressing the posterior capsule after resection of the collateral ligaments and for delivering antibiotic-loaded bone cement at the stems of the prosthesis for topic therapy. Disadvantages are the need for a higher level of constraint and a possible higher blood loss due to the radical debridement

The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different, in the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group. Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success. The authors' personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups. The authors' current indications for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection. Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component. The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is a extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000. A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems unfortunately may continue to go down as it is uncommonly taught in residency and fellowship, however it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons' armamentarium when treating patients undergoing primary and revision THA

Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30–150 microinches. RESULTS. Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results and Kaplan-Meier survivorship ranged from 90–99.5% in the best case scenario were noted at 10–20-year follow-up. CONCLUSION. With a properly-designed femoral stem, good cement technique, proper cement mantle, and surface roughness of 30–40 microinches, the cemented femoral stem provides a durable hip replacement in patients 60–80 years old with up to 95% survivorship at 10–20-year follow-up

Stems provide short- and long-term stability to the femoral and tibial components. Poorer epiphyseal and metaphyseal bone quality will require sharing or offloading the femoral and tibial component interfaces with a stem. One needs to use stem technique most appropriate for each individual case because of variable anatomy and bone loss situations. The conflict with trying to obtain stability via the stem is that most stems are cylindrical but femoral and tibial metaphyseal/diaphyseal areas are conical in shape. Viable stem options include fully cemented short and long stems, uncemented long stems, offset uncemented stems, and a hybrid application of a cemented proximal end of longer uncemented diaphyseal engaging stems. Stems are not without their risk. The more the load is transferred to the cortex, the greater the risk of proximal interface stress shielding. A long uncemented stem has similar stress shielding as a short cemented stem. Long diaphyseal engaging stems that are cemented or uncemented have the potential to have end of stem pain, especially if more diaphyseal reaming is done to obtain greater cortical contact. A conical shaped long stem can provide more stability than a long cylindrical stem and avoid diaphyseal reaming. Use of long stems may create difficulty in placement of the tibial and femoral components in an optimal position. If the femoral or tibial components do not allow an offset stem insertion, using a long offset stem or short cemented stem is preferred. The amount of metaphyseal bone loss will drive the choice of stem used. Short cemented stems will not have good stability in poor metaphyseal bone without getting the cement out to the cortex. Long cemented stems provide satisfactory survivorship, however, most surgeons avoid cementing long stems due to the difficulty of removal, if a subsequent revision is required. If the metaphyseal bone is excellent, use of a short cemented stem or long uncemented stem can be expected to have good results. Long fully uncemented stems must have independent stability to be effective, or should be proximally cemented as a hybrid technique. Cases with AOI type IIb and III tibial and femoral defects are best managed with use of metaphyseal cones with short cemented stems or long hybrid straight or offset stems. Some studies also suggest that if the cone is very stable, no stem may be required. My preference is to use a short cemented stem or hybrid conical stem in patients with good metaphyseal bone. If significant metaphyseal bone loss is present, I will use a porous cone with either a short cemented stem, hybrid cylindrical or offset stem depending on the primary stability of the cone and whether the femoral or tibial component can be placed in an optimal position in patients with good metaphyseal bone

Purpose. The purpose of this study was to evaluate the results of modular revision stems, uncemented fluted, tapered to treat periprosthetic femoral (PFF) fracture; we specifically evaluated fracture union, implant stability, patient outcomes, and complications to compare the differences between cemented and cementless primary stem. Materials and Methods. We retrospectively reviewed 56 cases of unstable periporsthetic femoral fracture (forty B2 and sixteen B3) treated with the uncemented fluted and tapered modular distal fixation stem with or with or without autogenous bone graft. Clinical outcomes were assessed with Harris Hip Score and WOMAC score. Radiologic evaluations were conducted using Beals and Tower's criteria. Any complication during the follow-up period was recorded. Results. The average follow-up period was 52.1±32.7 months. The average Harris Hip Score was 72.4±19.1. All fractures were united, and a good consolidation was achieved in 47 cases. There was femoral stem subsidence in 3 cases less than 10 mm without an evidence of loosening both radiologically and clinically. The radiologic results using Beals and Towers’ criteria were excellent in 36 hips, good in 10 hips and poor in 10 hips. Radiologic bone union took longer time and statistically significant stem subsidence was observed in cemented primary stem compared to cementless primary stem (Fig1,2). At each follow-up examination the clinical score was significantly higher in patients with cementless primary stem. Conclusion. Our results support the view that cement primary stem has less favorable result in terms of revision arthroplasty for periprosthetic femoral fractures

Introduction. There have been many attempts to reduce the risk of femoral component loosening. Using a tapered stem having a highly polished stem surface results in stem stabilization subsequent to debonding and stem-cement taper-lock and is consistent with force-closed fixation design. Purpose. In this study, we assessed the subsidence of two different polished triple tapered stems and two different cements in primary THA. Materials and methods. From March 2013 to March 2014, two kinds of polished triple tapered cemented stem were applied in 74 primary THA. 12 male, 62 female, mean age at surgery was 68 years old, mean F/U time was 12months. When they were compared by stems, this study comprises 35 THA with Trilliance stem(Aesculap, Germany) and 39 THA with SC stem (Kyocera, Japan), and when they were compared by cements, this study comprises 36 Simplex cement (Stryker, USA) cases and 38 Cobalt cement(Biomet, USA) cases. Using digitized x-ray, we measured the subsidence of each implants. Measurements were taken from initial postoperative radiographs to the final follow-up. We also evaluated the existence of radiolucent line between cement and stem and also evaluated calcar resorption. Results. The mean subsidence of Trilliance stem was 0.26mm and of SC stem was 0.44mm at 12months.(P<0.0001) Statistic significance was observed between the stems. When compared between 2 cements, the mean subsidence of Simplex cement was 0.25mm and of Cobalt cement was 0.48mm.(P=0.0563). No statistic significance was observed. There was no case of stem loosening and calcar resorption. Conclusion. 2 different designed cemented triple taper stems showed significantly different degree of subsidence after THA. No difference of subsidence was observed between two cements

Introduction. Total shoulder arthroplasty is the fastest growing joint replacement in recent years, with projected compound annual growth rates of 10% for 2016 through 2021 – higher than those of both the hip and knee combined. Reverse total shoulder arthroplasty (RTSA) has gained particular interest as a solution for patients with irreparable massive rotator cuff tears and failed conventional shoulder replacement, for whom no satisfactory intervention previously existed. As the number of indications for RTSA continues to grow, so do implant designs, configurations, and fixation techniques. It has previously been shown that continuous implant migration within the first two years postoperatively is predictive of later loosening and failure in the hip and knee, with aseptic loosening of implant components a guaranteed cause for revision in the reverse shoulder. By identifying implants with a tendency to migrate, they can be eliminated from clinical practice prior to widespread use. The purpose of this study is to, for the first time, evaluate the pattern and magnitude of implant component migration in RTSA using the gold standard imaging technique radiostereometric analysis (RSA). Methods. Forty patients were prospectively randomized to receive either a cemented or press-fit humeral stem, and a glenosphere secured to the glenoid with either autologous bone graft or 3D printed porous titanium (Aequalis Ascend Flex, Wright Medical Group, Memphis, TN, USA) for primary reverse total shoulder arthroplasty. Following surgery, partients are imaged using RSA, a calibrated, stereo x-ray technique, at 6 weeks (baseline), 3 months, 6 months, 1 year, and 2 years. Migration of the humeral stem and glenosphere at each time point is compared to baseline. Preliminary results are presented, with 15 patients having reached the 6-month time point by presentation. Results. Implant migration of ten participants at the 3-month time point is presented. Maximum total point motion (MTPM) is a measure of translation and rotation of the point on the implant that has moved the most from baseline. Average MTPM ± SD of the humeral stem is 1.18 ± 0.65 mm and 0.98 ± 0.46 mm for press-fit (n = 6) and cemented (n = 4) stems, respectively; and 0.25 ± 0.09 mm and 0.47 ± 0.24 mm for bone graft (n = 4) and porous titanium (n = 6) glenosphere fixations, respectively, at the 3-month time point. Conclusion. There is a trend towards increased migration with the use of press-fit humeral stems and porous titanium glenosphere fixation, though no conclusions can be made from the current sample size. Further, though differences in migration magnitude may be observed at early postoperative time points, it is expected that all fixation techniques will show stability from 1 to 2 years postoperatively