We report the outcome at a minimum of 10 years follow-up for 80 polished tapered stems performed in 53 patients less than 35-years-old with a high risk profile for aseptic loosening. Forty-six prosthesis were inserted for inflammatory hip arthritis and 34 for avascular necrosis. The mean age at surgery was 28 years in the inflammatory arthritis (17–35) and 27 years in the avascular necrosis (15–35) patients. At a mean follow-up of 14.5 years in the inflammatory arthritis group and 14 years in the avascular necrosis group respectively, survivorship of the 80 stems with revision of the femoral component for any reason as an endpoint was 100 % (95 % CI). Re-operation was because of failure of four metal-backed cups, 3 all polyethylene cups and one cementless cup. None of the stems were radiographically loose. All but two femoral components subsided within the cement mantle to a mean of 1.2 mm (0 tot 2.5) at final follow-up. Periarticular osteolysis was noted in 4 femurs in zone 7. This finding was associated with polyethylene wear and was only seen in those hips that needed revision for a metal backed cup loosening. Our findings show that the polished tapered stem has excellent medium-term results when implanted in young patients with high risk factors for aseptic loosening

Introduction. The success of total hip replacement in the young has consistently been worse both radiologically and clinically when compared to the standard hip replacement population. Methods. We describe the clinical and radiological outcome of 58 consecutive polished tapered stems (PTS) in 47 patients with a minimum of 10 years follow-up (mean 12 years 6 months) and compared this to our cohort of standard patients. There were 22 CPT stems and 36 Exeter stems. Results. Three patients with 4 hips died before 10 years and one hip was removed as part of a hindquarter amputation due to vascular disease. None of these stems had been revised or shown any signs of failure at their last follow-up. No stems were lost to follow-up and the fate of all stems is known. Survivorship with revision of the femoral component for aseptic loosening as the endpoint was zero and 4% (2 stems) for potential revision. The Harris hip scores were good or excellent in 81% of the patients (mean score 86). All the stems subsided within the cement to a mean total of 1.8mm (0.2-8) at final review. There was excellent preservation of proximal bone and an extremely low incidence of loosening at the cement bone interface. Cup failure and cup wear with an associated periarticular osteolysis was a serious problem. 19% of the cups (10) were revised and 25% of the hips (13) had significant periarticular osteolysis associated with excessive polyethylene wear. Discussion. The outcome of polished tapered stems in this age group is as good as in the standard age group and superior to other non PTS designs in young patients. This is despite higher weight and frequent previous surgery. Cup wear and cup failure were significantly worse in this group, with a higher incidence of periarticular osteolysis

In the 1960's Sir John Charnley introduced to clinical practice his low friction arthroplasty with a highly polished cemented femoral stem. The satisfactory long term results of this and other cemented stems support the use of polymethylmethacrylate (PMMA) for fixation. The constituents of PMMA remain virtually unchanged since the 1960s. However, in the last three decades, advances in the understanding of cement fixation, mixing techniques, application, pressurization, stem materials and design provided further improvements to the clinical results. The beneficial changes in cementing technique include femoral preparation to diminish interface bleeding, pulsatile lavage, reduced cement porosity by vacuum mixing, the use of a cement restrictor, pre-heating of the stem and polymer, retrograde canal filling and pressurization with a cement gun, stem centralization and stem geometries that increase the intramedullary pressure and penetration of PMMA into the cancellous structure of bone. Some other changes in cementing technique proved to be detrimental and were abandoned, such as the use of Boneloc cement that polymerised at a low temperature, and roughening and pre-coating of the stem surface. In the last two decades there has been a tendency towards an increased use of cementless femoral fixation for primary hip arthroplasty. The shift in the type of fixation followed the consistent, durable fixation obtained with uncemented acetabular cups, ease of implantation and the poor results of cemented femoral fixation of rough and pre-coated stems. Unlike cementless femoral fixation, modern cemented femoral fixation has numerous advantages: it is versatile, durable and can be used regardless of the diagnosis, proximal femoral geometry, natural neck version, and bone quality. It can be used in combination with antibiotics in patients with a history or predisposition for infection. Intra-operative femoral fractures are rare. However, the risk may be increased in collarless polished tapered stems. Post-operative thigh pain is extremely rare. Survivorship has not been surpassed by uncemented femoral fixation and it continues to be my preferred form of fixation. However, heavy, young, male patients may exhibit a slightly higher aseptic loosening rate

There has been an evolution in revision hip arthroplasty towards cementless reconstruction. Whilst cemented arthroplasty works well in the primary setting, the difficulty with achieving cement fixation in femoral revisions has led to a move towards removal of cement, where it was present, and the use of ingrowth components. These have included proximally loading or, more commonly, distally fixed stems. We have been through various iterations of these, notably with extensively porous coated cobalt chrome stems and recently with taper-fluted titanium stems. As a result of this, cemented stems have become much less popular in the revision setting. Allied to concerns about fixation and longevity of cemented fixation revision, there were also worries in relation to bone cement implantation syndrome when large cement loads were pressurised into the femoral canal at the time of stem cementation. This was particularly the case with longer stems. Technical measures are available to reduce that risk but the fear is nevertheless there. In spite of this direction of travel and these concerns, there is, however, still a role for cemented stems in revision hip arthroplasty. This role is indeed expanding. First and foremost, the use of cement allows for local antibiotic delivery using a variety of drugs both instilled in the cement at the time of manufacture or added by the surgeon when the cement is mixed. This has advantages when dealing with periprosthetic infection. Thus, cement can be used both as interval spacers but also for definitive fixation when dealing with periprosthetic hip infection. The reconstitution of bone stock is always attractive, particularly in younger patients or those with stove pipe canals. This is achieved well using impaction grafting with cement and is another extremely good use of cement. In the very elderly or those in whom proximal femoral resection is needed at the time of revision surgery, distal fixation with cement provides a good solution for immediate weight bearing and does not have the high a risk of fracture seen with large cementless stems. Cement is also useful in cases of proximal femoral deformity or where cement has been used in a primary arthroplasty previously. We have learnt that if the cement is well-fixed then the bond of cement-to-cement is excellent and therefore retention of the cement mantle and recementation into that previous mantle is a great advantage. This avoids the risks of cement removal and allows for much easier fixation. Stems have been designed specifically to allow this cement-in-cement technique. It can be used most readily with polished tapered stems - tap out a stem, gain access at the time of revision surgery and reinsert it. It is, however, now increasingly used when any cemented stems are removed provided that the cement mantle is well fixed. The existing mantle is either wide enough to accommodate the cement-in-cement revision or can be expanded using manual instruments or ultrasonic tools. The cement interface is then dried and a new stem cemented in place. Whilst the direction of travel in revision hip arthroplasty has been towards cementless fixation, particularly with tapered distally fixed designs, the reality is that there is still a role for cement for its properties of immediate fixation, reduced fracture risk, local antibiotic delivery, impaction grafting and cement-in-cement revision

The technique involves impaction of cancellous bone into a cavitary femur. If segmental defects are present, the defects can be closed with stainless steel mesh. The technique requires retrograde fill of the femoral cavity with cancellous chips of appropriate size to create a new endomedullary canal. By using a set of trial impactors that are slightly larger than the real implants the cancellous bone is impacted into the tube. Subsequent proximal impaction of bone is performed with square tip or half moon impactors. A key part of the technique is to impact the bone tightly into the tube especially around the calcar to provide optimal stability. Finally a polished tapered stem is cemented using almost liquid cement in order to achieve interdigitation of the implant to the cancellous bone. The technique as described is rarely performed today in many centers around the world. In the US, the technique lost its interest because of the lengthy operative times, unacceptable rate of peri-operative and post-operative fractures and most importantly, owing to the success of tapered fluted modular stems. In centers such as Exeter where the technique was popularised, it is rarely performed today as well, as the primary cemented stems used there, rarely require revision. There is ample experience from around the globe, however, with the technique. Much has been learned about the best size and choice of cancellous graft, force of impaction, surface finish of the cemented stem, importance of stem length, and the limitations and complications of the technique. There are also good histology data that demonstrate successful vascularization and incorporation of the impacted cancellous bone chips and host bone. Our experience at the clinic was excellent with the technique as reported in CORR in 2003 by M Cabanela. The results at mid-term demonstrated minimal subsidence and good graft incorporation. Six of 54 hips, however, had a post-operative distal femoral fracture requiring ORIF. The use of longer cemented stems may decrease the risk of distal fracture and was subsequently reported by the author after reviewing a case series from Exeter. Today, I perform this technique once or twice per year. It is an option in the younger patient, where bone restoration is desired. Usually in a Paprosky Type IV femur, where a closed tube can be recreated and the proximal bone is reasonable. If the proximal bone is of poor quality, then I prefer to perform a transfemoral osteotomy, and perform an allograft prosthetic composite instead of impaction grafting, and wrap the proximal bone around the structural allograft. I prefer this technique as I can maintain the soft tissues over the bone and avoid the stripping that would be required to reinforce the bone with struts or mesh. Another indication for its use in the primary setting is in the patient with fibrous dysplasia

Introduction:. The risk for late periprosthetic fractures is higher in patients treated for a neck of femur fracture compared to those treated for osteoarthritis. It has been hypothesised that osteopenia and consequent decreased stiffness of the proximal femur are responsible for this. We investigated if a femoral component with a bigger body would increase the torque to failure in a biaxially loaded composite sawbone model. Method:. A biomechanical composite sawbone model was used. Two different body sizes (Exeter 44-1 vs 44-4) of a polished tapered cemented stem were implanted by an experienced surgeon, in 7 sawbones each and loaded at 40 deg/s internal rotation until failure. Torque to fracture and fracture energy were measured using a biaxial materials testing device (Instron 8874). Data are non-parametric and tested with Mann-Whitney U-test. Results:. The mean torque load to fracture was 154.1 NM (SD 4.4) for the 44-1 stem and 229 NM (SD10.9) for the 44-4 stem (p = 0.01). The mean fracture energy was 9.6 J (SD1.2) for the 44-1 stem and 17.2 J (SD2.0) for the 44-4 stem (p = 0.14). Conclusion:. the use of a large body polished tapered cemented stem for neck of femur fractures increases the torque to failure in a biomechanical model and therefore is likely to reduce late periprosthetic fracture risk in this vulnerable cohort

Introduction. The French paradox regarding cemented femoral components has not been resolved, so we compared the mechanical behavior of a French stem, the CMK stem (Biomet, Warsaw, IN, USA), with a collarless, polished, tapered stem (CPT, Zimmer, Warsaw, IN, USA) using an original biomechanical instrument. Materials and Methods. Two size-3 CPT stems and two size-302 CMK stems stems were fixed with bone cement into a composite femur soaked in vegetable oil to simulate wet condition. The composite femur was attached to a biomechanical testing instrument after stem implantation, and a 1-Hz dynamic sine wave load (3000 N) was applied to the stems for a total of 1 million cycles. An 8-hour unload period was set after every 16 hours of load. Femur temperature was maintained at 37°C during testing. The femoral canal was prepared for the CPT stems by standard rasping; for the CMK stems, however, the French method was used, in which cancellous bone was removed with a reamer. One CMK stem (CMK-1) was inserted into a femur without collar contact (>2 mm above the calcar), and the other (CMK-2) was inserted into a femur with collar contact. Stem subsidence was measured at the stem shoulder. Compressive force and horizontal cement movement were measured via rods set at the cement–bone interface on the medial, lateral, anterior, and posterior sides of the proximal and distal portions of the composite femurs. Results. Subsidence was as follows: 0.521 mm and 0.629 mm for the CPT stems, 0.46 mm for CMK-1, and 0.36 mm for CMK-2. Compressive force at the cement–bone interface was at the maximum level at the proximomedial portion of all stems. These forces increased gradually until the one-millionth loading. Maximum compressive forces were 183 N and 107 N for the CPT stems, 180 N for CMK-1, and 215 N for CMK-2. There was a strong positive correlation between stem subsidence and compressive force in all stems. Radial cement creep at the proximomedial portion was 90 μ for one of the CPT stems, 184 μ for CMK-1, and −636 μ for CMK-2. Discussion. We previously reported our findings of a positive correlation between stem subsidence and compressive force in CPT stems. In the current study, CMK stems also subsided even when there was stem collar contact with bone. Subsidence was less in CMK stems than in CPT stems, but the values were close. In addition, compressive force and radial cement creep in CMK stems were also similar to or greater than in CPT stems. Conclusion. The two different concept stems demonstrated similar behavior in relation to bone cement, a finding that may present a solution to the French paradox

Background. BOA Guidelines recommend clinical and radiological follow-up after primary total hip arthroplasty (THA) at 1 and 5 years, and every 5 years thereafter to detect asymptomatic failure and allow early intervention. As revision surgery in asymptomatic patients is rare the need for routine follow-up in well-functioning individuals has recently been questioned. To evaluate the role of routine follow-up out-patient appointments (OPA) in identifying failing implants the modes of presentation for patients undergoing revision THA were reviewed. Methods. 176 patients who received 183 revision THAs (2003–2010) were identified from an arthroplasty database. 124 patients who received 131 first time revision THAs after primary cemented total hip arthroplasty met inclusion criteria. Retrospective notes review was performed to investigate symptoms at failure and mode of presentation. Results. Most patients were seen as referrals from other specialities. Only 25% were detected via routine follow-up OPAs. The mode of initial presentation was GP 60%, routine orthopaedic OPA 25%, A&E 9%, hospital inpatient 4%, rheumatology 2%. No patients were asymptomatic. Predominant symptoms were pain 99%, impaired mobility 80%, limp 44%, stiffness 25%, night pain 22%, systemic symptoms 8%. Estimated minimum cost of routine OPA was £35. For the 377 primary THRs performed in 2009 the saving at one year with discharge after 3months would be £13149. Assuming mean 15 year survival £52780 would be saved over the cohort lifespan. Conclusions. Following uncomplicated primary cemented THA with our combination of polished tapered stem and flanged cup failure is unlikely to occur without symptoms. Symptomatic patients present mainly via their GP and other specialities and are mostly seen as new or re-referrals rather than being detected via routine OPAs. With appropriate advice, discharge after the earliest clinic when the patient has returned to full normal activities is potentially safe and could lead to significant savings

We have prospectively followed up 191 consecutive primary total hip replacements utilising a collarless polished tapered (CPT) femoral stem, implanted in 175 patients between November 1992 and November 1995. At a mean follow-up of 15.9 years (range 14 – 17.5) 86 patients (95 hips) were still alive (25 men and 61 women) and available for routine follow up. Clinical outcome was determined from a combination of the Harris (HHS) and Oxford (OHS) hip scores. Radiological assessment was with antero-posterior radiographs of both hips and a lateral radiograph of the operated hip. The radiographs were evaluated using well-recognised assessment techniques. There was no loss to follow up, with clinical data available on all 95 hips. Five patients were too frail to undergo radiographic assessment, therefore radiological assessment was performed on 90 hips (95%). At the latest follow-up, the mean HHS was 78 (range 28 – 100) and the mean OHS was 36 (range 15 – 48). Stems subsided within the cement mantle, with a mean total subsidence of 2.1mm (range 0.4 – 24). Higher grades of heterotopic bone formation were significantly associated with males (p<0.001) and hypertrophic osteoarthritis (p<0.001). Acetabular wear was associated with increased weight (p<0.001) and male sex (p=0.005). Amongst the cohort, only 1 stem (1.1%) has been revised due to aseptic loosening. This patient required reaming of their canal prior to implantation, as a result of a previous femoral osteotomy. The rate of stem revision for any cause was 7.4% (7 stems), of which 4.2% (4 stems) resulted from infection following revision of the acetabular component. Twenty patients (21.1%) required some sort of revision procedure; all except 3 of these resulted from failure of the acetabular component. Cemented cups had a significantly lower revision burden (2.7%) than Harris Galante uncemented components (21.8%) (p<0.001). The CPT stem continues to provide excellent radiological and clinical outcomes at 15 years following implantation. Its results are consistent with other polished tapered stem designs. Cup failure remains a problem and is related in part to inadequate bearings and biological abnormalities

Introduction. The Exeter cemented polished tapered stem design was introduced into clinical practice in the early 1970's. [i] Design and cement visco-elastic properties define clinical results [ii]; a recent study by Carrington et al. reported the Exeter stem has 100% survivorship at 7 years. [iii] Exeter stems with offsets 37.5–56 mm have length 150 mm (shoulder to tip). Shorter stems, lengths 95–125 mm, exist in offsets 30–35.5 mm. The Australian National Joint Replacement Registry recently published that at 7 years the shorter stems are performing as well as longer stems on the registry [iv]. Clinical observation indicates in some cases of shorter, narrower femora that fully seating a 150 mm stem's rasp in the canal can be difficult, which may affect procedural efficiency. This study investigates the comparative risk of rasp distal contact for the Exeter 150 mm stem or a 125 mm stem. Materials and Methods. Rasps for 37.5, 44, 50 mm offset, No.1, 150 mm length stems (Exeter, Stryker Orthopaedics, Mahwah NJ) were compared with shortened length models using SOMA™ (Stryker Orthopaedics Modeling and Analytics technology). 637 patients' CT scanned femora were filtered for appropriate offset and size by measuring femoral-head to femoral-axis distance and midsection cancellous bone width (AP view). These femora were analyzed for distal contact (rasp to cortices) for 150 mm and 125 mm models (Figure 1). The widths of the rasp's distal tip and the cancellous bone boundary were compared to assess contact for each femur in the AP and ML views; the rasp was aligned along an ideal axis and flexed in order to pass through the femoral neck (ML view only). Results. The sample size of appropriate patients totaled 238 femora. In the AP view, the rasp exhibited contact in 43 cases for a 150 mm stem but in 0 cases for a 125 mm stem; 95% of bones with contact were Champagne Fluted. In the ML view, rasp distal contact occurred in 52 femora for a 150 mm stem and in 1 femur for a 125 mm stem (Table 1). The difference was significant in both views with p < 0.001. Discussion. This study shows that a shortened stem design's rasp avoids distal contact. Shorter stem rasps resolved all cases where there was a risk of contact with a 150 mm rasp and reduced the likelihood of contact (one case compared to 52), AP and ML views respectively. These results indicate that shorter stems may address patients with champagne-fluted and/or excessively bowed femora, commonly found in the Asian population[v]. Contact avoidance may improve rasp seating height (AP view) and alignment with the femoral axis (ML view), thereby increasing procedural efficiency and producing an optimal cement mantle distally.[vi] The data shows that a total 29% of appropriate model patients would benefit from a shorter stem. Shorter cemented stems may effectively address the global population's needs in THR

Purpose. To evaluate the radiographic long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. Materials and methods. Among 28 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 9 years 6 months to 14 years 5 months (mean, 12, 5 years). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis. Results. Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 5 mm) and 1 stem showed moderate subsidence (about 10 mm) in the cement. But there was no mechanical failure and subsidence at the composit-femur interface. Evidence of cortical and trabecular remodeling were observed in all cases. No radiolucent line or osteolysis were found in the follow-up period. There were 4 proximal femoral cracks and 1 distal femoral splitting during operation. Conclusion. The result of cemented stem revision with the use of impacted cancellous allograft was good long-terand femoral bone stock deficiency may be reconstructed successfully

Introduction:. In an attempt to reduce stress shielding in the proximal femur multiple new shorter stem design have become available. We investigated the load to fracture of a new polished tapered cemented short stem in comparison to the conventional polished tapered Exeter stem. Method:. A total of forty-two stems, twenty-one short stems and twenty-one conventional stems both with three different offsets were cemented in a composite sawbone model and loaded to fracture. Results:. study showed that femurs will break at a significantly lower load to failure with a shorter compared to conventional length Exeter stem. Conclusion:. This Both standard and short stem design are safe to use as the torque to failure is 7–10 times as much as the torques seen in activities of daily living

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

A large body of the orthopaedic literature clearly indicates that the cement mantle surrounding the femoral component of a cemented total hip arthroplasty should be at least 2 mm thick. In the early 1970s, another concept was introduced and is still in use in France consisting of implanting a canal filling femoral component line-to-line associated with a thin cement mantle. This principle has been named the “French paradox”. An explanation to this phenomenon has been provided by in-vitro studies demonstrating that a thin cement mantle in conjunction with a canal filling stem was supported mainly by cortical bone and was subjected to low stresses. We carried out a study to evaluate the in-vivo migration patterns of 164 primary consecutive Charnley-Kerboull total hip replacements. All prosthesis in the current series combined an all-polyethylene socket and a 22.2 mm stainless steel femoral head. The monobloc double tapered (5.9 degrees) femoral component was made of 316L stainless steel with a highly polished surface (Ra = 0.04 μm), a quadrangular section, and a neck-stem angle of 130 degrees. The stem was available in six sizes with a stem length (shoulder to tip) ranging from 110 mm to 160 mm, and a neck length ranging from 24 mm to 56 mm. For each size, the femoral component was available in two to four different diameters to adapt the implant to the medullary canal. Hence the whole range comprised a total of 18 standard femoral components. The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational and varus/valgus stability of the stem prior to the line-to-line cementation. We used the Ein Bild Roentgen Analyse Femoral Component (EBRA-FCA) method to assess the subsidence of the femoral component. At the minimum 15-year follow-up, 73 patients were still alive and had not been revised at a mean of 17.3 years, 8 patients had been revised, 66 patients were deceased, and 8 patients were lost to follow-up. The mean subsidence of the entire series was 0.63 ± 0.49 mm (0 – 1.94 mm). When using a 1.5 mm threshold, only four stems were considered to have subsided. With revision of either component for any reason as the endpoint, the cumulative survival rate at 17 years was 90.5 ± 3.2% (95% CI, 84.2% to 96.8%). With radiological loosening of the femoral component as the endpoint, the cumulative survival rate at 17 years was 96.8 ± 3.1% (95% CI, 93.2% to 100%). This study demonstrated that, in most cases, a highly polished double tapered stem cemented line-to-line does not subside up to 18-year follow-up

Favourable long-term results have been reported with the standard Exeter cemented stem. We report our experience with a version for use in smaller femora, the Exeter 35.5 mm stem. Although, also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem. Between August 1988 and August 2003, 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 years (18 to 86), with 73 patients under the age of 50 years. The diagnosis was osteoarthritis in 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in three, secondary to Perthes disease in two and avascular necrosis of the hip in one patient. The fate of every implant is known. At a median follow-up of 8 years (5 to 19), survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Fifteen cases (7.8%) underwent further surgery 11 for acetabular revision, one for stem fracture and three others. Although, smaller than a standard Exeter Universal polished tapered cemented stem—with a shorter, slimmer taper—the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients

Femoral impaction grafting with cancellous bone and cement is an important technique in reconstituting deficient bone stock in revision hip arthroplasty. We report the medium to long term results of 75 consecutive patients using a collarless, polished, tapered femoral stem with an average age of 68 (±11.4) years and a mean follow up of 10.5 (±2.4) years (range 6.3 to 14.1 years). The median Endoklinik pre-operative bone defect score was 3 (IQR: 2–3) with a median subsidence at 1 year of 2mm (IQR: 1–3mm). At the most recent follow-up (mean 10.5±2.4 years), the median Harris Hip Score (HHS) was 80.6 (IQR: 67.6–88.9) and median subsidence 2mm (IQR: 1–4mm). Ten-year survivorship with any further femoral operation as an endpoint was 92%. Four prostheses required further revision. Subsidence of the Exeter stem continued, albeit at a slower rate after the first year and was related to the Endoklinik pre-operative bone loss (p=0.037). The degree of subsidence at 1 year was a strong predictor of long term subsidence (p<0.001). Neither subsidence nor bone stock were related to long term outcome (HHS). There was a correlation between previous revision surgery and a poor Harris Hip Score (p=0.028) and those who had undergone previous revision surgery for infection had a higher risk of complications (p=0.048). The good long term results of this technique commend its use in revision hip arthroplasty for patients with poor femoral bone stock

Introduction. Segmental defects of the femur present a major problem during revision hip arthroplasty. In particular, calcar segmental defects may compromise initial and long-tem femoral stem stability. Objective. The objective of the present study is to assess mid-term clinical and radiographic follow-up results at least two years after femoral revision comprising reconstruction for calcar segmental defect using metal wire mesh and impacted morcellised allograft. Methods. We performed 26 femoral revisions with calcar reconstruction in 24 patients between 2002 and 2010. The average age was 69.7 years, and the average follow-up period was 5 years and 1 month. All surgeries were performed using a cemented polished collarless tapered stem. The segmental calcar defect was reconstructed with metal wire mesh with doubled stainless wires. Large sized morcellised cancellous allograft was tightly impacted into the cavity between the phantom stem and the metal wire mesh. Nineteen hips were reconstructed with impaction bone grafting of the femur, and 7 hips with cement-in-cement technique except for the reconstructed calcar region.ã�� For clinical assessment, Merle d'Aubigné and Postel hip scores were recorded. For radiological assessment, antero-posterior hip radiographs were analyzed pre-operatively, and post-operatively at one month, 6 months and every 6 months thereafter. Clear lines around the femoral component using Gruen zone classification, stem subsidence in cement mantle, and change of stem axis were recorded. Kaplan-Meier survival analyses were performed with any re-operation of the femoral component or aseptic loosening as end points. In one case, the histological appearance of a biopsy specimen of the most proximal part of the reconstructed calcar, which was obtained at a later surgery for infection at 4 years after the revision, is described. Results. For clinical assessment, the mean Merle d'Aubigné and Postel hip scores improved from 10.4 points before the operation to 14.7 points at the final follow-up. For radiological assessment, no clear lines at the cement-bone interface and no stem axis changes were detected. Twenty-five of 26 hips showed less than 2 mm of stem subsidence at the final follow-up and one hip showed 2.2 mm stem subsidence. Both hips of one female patient underwent a one stage stem exchange because of an infection that occurred 48 months after revision. No cases showed aseptic loosening up to and including the last follow-up. The Kaplan-Meier survival analysis revealed that the survival rate at five years after revision was 88.0% with any type of re-operation on the femoral side as the endpoint and 100% with aseptic stem loosening as the endpoint, respectively. A biopsy specimen taken from the most proximal part of the reconstructed calcar region at 4 years after surgery in the infected case showed almost complete regeneration of viable bone with normal marrow spaces with partially formed granulation tissue. Conclusion. Reconstruction using metal wire mesh and tightly impacted morcellised allograft is a favorable method for the correction a calcar segmental defect. The procedure is simple and reliable, achieving initial and mid-term stem stability even for femurs with a complete calcar defect