Cement-within-cement stem exchange using the collarless polished double-taper stem

Multi-centre study of cement-in-cement and in-cement femoral revision total hip arthroplasty using polished, stainless steel stems

BACKGROUND

Exposure of the acetabular component during revision total hip arthroplasty is often difficult and stems are often difficult to remove. Polished and tapered cemented stems are easily removed and can be easily reconstructed by either cement-in-cement or in-cement technique. This study was a retrospective review of the medium-term outcomes of revision total hip arthroplasty conducted with the Exeter stem fixed by cement-in-cement or in-cement method in four institutions.

METHODS

This study included hips (n = 103) reconstructed by cement-in-cement or in-cement technique on the femoral side during revision total hip arthroplasty in four institutions between 2003 and 2015. The mean age at surgery was 71.1 years (range, 43-86 years), and the mean follow-up period was 5.6 years (range, 0-13 years).

RESULTS

Revision arthroplasty was required for acetabular component complications in 69 hips, for dislocation in 25, for infection in eight, and for stem fracture in one hip. Re-revision was required in 10 hips for: infection (n = 6), acetabular component complications (n = 3), and dislocation (n = 1). No radiographic loosening, cement fractures, or osteolysis of the femoral components were observed. Ten-year survival rate was 99% with the endpoint of femoral revision surgery, and 100% with the endpoint of femoral aseptic loosening.

CONCLUSIONS

The medium-term outcomes of revision total hip arthroplasty on the femoral side conducted using the cement-in-cement or in-cement technique were favourable, with no cases of aseptic loosening. As long as the bone-cement interface remains robust, there is no need to remove all the cement, and the cement-in-cement or in-cement technique should be used for reconstruction.

Cement-in-cement versus uncemented modular stem revision for Vancouver B2 periprosthetic fractures

Background

To compare outcomes of revision to a long uncemented stem with cement-in-cement revision for Vancouver B2 periprosthetic fracture (PPF).

Methods

Patients undergoing surgery for a Vancouver B2 PPF in a cemented stem from 2008 to 2018 were identified using our prospectively collated database.

Results

We identified 43 uncemented and 29 cement-in-cement revisions. Cement-in-cement revision had a shorter operative time, reduction in certain complications, no increased rate of non-union, lower degree of stem subsidence and no difference in re-revision rate.

Conclusion

With appropriate patient selection, both cement-in-cement and long uncemented stem revision represent appropriate treatment options for Vancouver B2 fractures.

Cement-in-cement femoral component revision : a comparison of two different taper-slip designs with medium-term follow up

AIMS

Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components.

METHODS

From our prospectively collated database, we identified all patients undergoing cement-in-cement revision from January 2005 to January 2013 who had a minimum of two years' follow-up. All cases were performed by the senior author using either an Exeter short revision stem or the C-Stem AMT high offset No. 1 prosthesis. Patients were followed-up annually with clinical and radiological assessment.

RESULTS

A total of 97 patients matched the inclusion criteria (50 Exeter and 47 C-Stem AMT components). There were no significant differences between the patient demographic data in either group. Mean follow-up was 9.7 years. A significant improvement in Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-item Short-Form Survey (SF-12) scores was observed in both cohorts. Leg lengths were significantly shorter in the Exeter group, with a mean of -4 mm in this cohort compared with 0 mm in the C-Stem AMT group. One patient in the Exeter group had early evidence of radiological loosening. In total, 16 patients (15%) underwent further revision of the femoral component (seven in the C-Stem AMT group and nine in the Exeter group). No femoral components were revised for aseptic loosening. There were two cases of femoral component fracture in the Exeter group.

CONCLUSION

Our series shows promising mid-term outcomes for the cement-in-cement revision technique using either the Exeter or C-Stem AMT components. These results demonstrate that cement-in-cement revision using a double or triple taper-slip design is a safe and reliable technique when used for the correct indications. Cite this article: Bone Joint J 2021;103-B(7):1215-1221.

Cement-in-cement technique of the femoral component in aseptic total hip arthroplasty revision: A systematic review of the contemporary literature

Background

Clinical outcomes of cemented femoral stems revisions using the cement-in-cement technique in aseptic conditions after total hip arthroplasty have been widely described.

Methods

The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried.

Results

Twelve articles were included (620 revision THA). Revision rate for complications related to the femoral side was 1.4% at mid-term follow-up (5.4 years). Periprosthetic femoral fracture rate was 1.1%, aseptic loosening of the femoral component 0.3%.

Conclusions

Cement-in-cement revision technique of the femoral component is associated with a high mid-term success rates (98.6%) and is potentially less challenging than other revision techniques.

Systematic Biomechanical Analysis of Prerequisites for Reliable Intraoperative Bonding of Polymethylmethacrylate Bone Cement in Preexisting Cement in Revision Arthroplasty

Removal of a stable cement mantle may be invasive and time consuming and may result in unnecessary damage to bone and surrounding soft tissue. The goal of this study was to investigate the feasibility of the use of polymethylmethacrylate cement on preexisting cement as well as to explore the prerequisites for practical clinical use under standardized laboratory conditions. The strength of the cement-cement interface was evaluated with a 4-point bending to failure test, according to International Organization for Standardization 5833, as well as standardized shear strength, according to American Society for Testing and Materials D732. Various intraoperative cleaning agents were tested to remove simulated contamination with bone marrow. Contamination of the cement-cement interface with bone marrow decreases bending strength, modulus, and shear strength. Removal of the bone marrow with a degreasing agent significantly increases bending strength as well as bending modulus and can increase shear strength up to 9% compared with use of a nondegreasing agent. The cement-cement interface may reach up to 85% of bending strength, 92% of bending modulus, and comparable shear strength compared with a uniform cement block. Meticulous removal of fatty contaminant is important. Use of a degreasing agent further increases the stability of the cement-cement interface. With these precautions, it is safe to assume that the combined molecular and mechanical interlock is sufficient for most clinical applications and will not represent the weakest link in prosthetic revision. [Orthopedics. 2021;44(1):e55-e60.].

The cement-in-cement technique is a reliable option in hip arthroplasty revision surgery: a systematic review

INTRODUCTION

The cement-in-cement technique for revision hip arthroplasty has many potential advantages and has recently gained widespread interest but still lacks evidence to support it. Our aim was to examine the surgical and patient-reported outcomes after cement-in-cement revision hip arthroplasty.

MATERIALS AND METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE databases were searched up to February 2019 for original studies reporting the outcomes of revision hip arthroplasty surgeries using the cement-in-cement technique. The methodological quality was assessed using the methodological index for non-randomized studies scale.

RESULTS

Sixteen non-comparative studies met the eligibility criteria, comprising 1899 hips in 1856 patients (72.2 mean age, 37% male), with a mean follow-up of 7.2 years. Most studies reported only primary revisions and focused on the stem component. Intraoperative complications such as femoral or acetabular fractures (5.3%) were low and easily manageable with no relevant sequelae, as were dislocation rates (2.8% of uncomplicated events and 1.6% of cases requiring re-revision). Failure (considered if there was aseptic loosening of the cement-in-cement revised component, 2%), re-revision (9.3%), implant survival and late complication rates were favourable. Functional patient-reported outcomes showed an overall improvement above the minimal clinically important difference at final follow-up.

CONCLUSION

The cement-in-cement technique is a viable option for hip arthroplasty revision surgery with low intraoperative and late complication rates, dislocations and immediate post-operative morbidity, resulting in good functional patient-reported outcomes and favourable medium-term implant survival.

Optimizing humeral stem fixation in revision reverse shoulder arthroplasty with the cement-within-cement technique

BACKGROUND

The purpose of this study was to report on the clinical outcomes of patients undergoing revision reverse shoulder arthroplasty (RSA) by the cement-within-cement technique, as well as to identify whether surgical technique can affect subsequent humeral loosening.

METHODS

In 98 patients, cemented humeral components that were revised to RSA using the cement-within-cement technique were identified and included in this study. We compared 8 patients in whom humeral stem loosening developed with 90 patients whose stem remained fixed. Preoperative and postoperative radiographs of each patient were downloaded in DICOM (Digital Imaging and Communications in Medicine) format and analyzed in Mimics. The total area of the cement mantle (in square millimeters) and of the stem (in square millimeters), as visualized on 2-dimensional plain films, was measured in each subject on both preoperative and postoperative radiographs. Outcomes at a minimum of 2 years of follow-up were analyzed.

RESULTS

Clinical outcomes were available in 57 patients, with a mean follow-up period of 54 months (range, 21-156 months). Patients demonstrated significantly improved functional outcome scores and shoulder range of motion. In the group without loosening, the mean increase in the cement mantle area was 4380 ± 12701 mm² (P < .0001). In the group with loosening, the mean increase in the cement mantle area was only 811 ± 4014 mm² (P = .484).

CONCLUSIONS

Use of the cement-within-cement technique for fixation of the humeral component in revision RSA is effective in improving functional outcome scores and shoulder range of motion. Furthermore, these findings suggest that efforts to maximize the cement volume during reimplantation may lessen the chance of humeral stem loosening requiring additional revision.

Cement-in-cement revision with the Exeter Short Revision Stem: A review of 50 consecutive hips

Revision of a well-fixed cemented femoral stem is technically challenging. The Exeter Short Revision Stem (SRS) was developed to facilitate cement-in-cement revision mitigating some of these challenges. We present the short to mid-term results of 50 cement-in-cement revisions performed with this implant. A retrospective review of all cement-in-cement revision with the Exeter SRS, at our institution, over a seven-year period between 2007 and 2014 was conducted. Records were assessed for radiological and clinical component loosening at greater than 12 months follow-up and for revision and complications at all time points. An Oxford Hip Score (OHS) and Numeric Rating Scale (NRS) for groin and thigh pain at rest and initial mobilisation were obtained. 50 implants in 46 patients were identified. Radiographic and clinical follow-up was available for 42 and 38 implants respectively at greater than 12 months. Mean radiographic follow-up was 5.1 years and clinical 4.9 years. There was no radiographic or clinical evidence of loosening. 3 revisions were performed, one for each of recurrent dislocation, infection and stem breakage. Median OHS was 39 (IQR 12) and mean NRS for groin pain at rest and initial mobilisation was 1.7 and 1.7 respectively and NRS for thigh pain at rest and initial mobilisation was 1.3 and 1.6 respectively with mean follow-up of 6.9 years. The Exeter SRS provides a viable option for cement-in-cement stem revision, with low revision, complication and loosening rates and good patient reported outcomes at short to mid-term follow up.

Outcomes of Cement in Cement Revision, in Revision Total Hip Arthroplasty

BACKGROUND

The cement-in-cement femoral revision technique involves removing a femoral component from a well-fixed femoral cement mantle and cementing a new stem into the original mantle. This technique, when carried out for the correct indications, is fast, relatively inexpensive and carries a reduced short-term risk for the patient compared with conventional way of removing well-fixed cement.

AIM

To analyze the effectiveness of cement in cement revision of the femoral stem while performing a revision Total Hip Arthroplasty (THA).

METHODS

We analyzed a consecutive series of 79 patients who underwent a cement in cement revision THA between June-2015 to June-2018. All the patients were retrospectively analysed for operative time, complications, clinical and radiological outcomes.

RESULTS

Average age was 76 years (49-86). The mean follow-up was 16.2 months (12-45). The average operative time was 184.6 (90-290) minutes. Most common indication was cup loosening in 28 patients (42.4%), dislocation in 14 patients (21.2%) and stem loosening in 12 patients (18.2%) Nine patients (11%) had one or more complications. Pre-operatively, 10 patients (13%) had lucency at the cement bone interface. Recent review has shown that 8 of these patients' radiographs have remained unchanged, and in 2 of them there is a slight progression of lucency. Common post op clinical complaintswere persistent pain and abductor weakness. Five (6.3%) patients required a re-revision. Most of the patients had a good or satisfactory outcome.No stems showed radiological loosening.

CONCLUSION

The cement-in-cement technique for revision of the femoral component gave promising results and had the advantages of speed, less blood or bone stock loss, less risk of femoral perforation or fracture, decreased financial costs and reduced post op morbidity.

Difficulties associated with the variable geometry of different-offset Exeter long stems in cement-in-cement technique: A case report

Although the cement in cement technique is a simple method for exchanging cemented stems, it may be technical demanding. The different geometry of different-offset Exeter long stems can be a problem with this technique. We describe a case revision hip surgery as a consequence of neglected bipolar hemiarthroplasty dislocation in which a 44 mm offset long stem was exchanged by a shorter and smaller size 37.5 mm offset stem. The implications of the procedure and the surgical pitfalls are discussed.

Cement-within-cement technique in revision reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the complications and results of cement-within cement-humeral fixation in revision reverse shoulder arthroplasty.

METHODS

In 38 shoulders, a cemented humeral component was revised to a cemented reverse humeral component using a cement-within-cement technique. The mean follow-up time was 3.7 (2.0-7.0) years. Clinical, radiologic, and hard outcomes were assessed using the Kaplan-Meier survival method, Fisher exact test, and Student t-test.

RESULTS

The average operative time for the cement-within-cement technique was 153 minutes. There were 7 (18%) nondisplaced intraoperative fractures involving the greater tuberosity that occurred on implant removal; all healed at last follow-up. A second revision surgery was performed in 3 (8%) patients who underwent cement-in-cement humeral component revision for glenoid loosening (n = 1), periprosthetic instability associated with glenoid loosening (n = 1), and periprosthetic humerus fracture (n = 1). The overall implant revision-free survival at 2 and 5 years was 95% and 91%, respectively. Patients experienced significant pain relief, improvements in their shoulder range of motion, and high satisfaction. There was 1 "at-risk" humeral component (grade 4 or higher humeral lucency, moderate subsidence) that did not undergo revision surgery. There were 2 other humeral components with grade 3 humeral lucency, no subsidence.

CONCLUSIONS

Cement-within-cement fixation of the humeral component in revision reverse shoulder arthroplasty is associated with a reasonable operative time, good medium-term survival rates, and good pain relief and functional outcomes with low complications. This technique is an important consideration to preserve humeral bone stock and potentially humeral component and implant stability.

Advantages in Using Cemented Polished Tapered Stems When Performing Total Hip Arthroplasty in Very Young Patients

BACKGROUND

The risk of revision following primary total hip arthroplasty (THA) is increased in young patients who undergo THA for pathologies other than primary osteoarthritis. We report the results of primary THA performed with cemented polished stems in patients aged 40 years and younger for pathologies other than primary osteoarthritis.

METHODS

We investigated 52 patients (65 hips) who underwent primary THA for secondary osteoarthritis with a cemented tapered polished stem between 1990 and 2007. Clinical and radiographic outcomes, available in 46 patients (57 hips), included the Harris Hip Scores, Societe Internationale de Chirurgie Orthopedique et de Traumatologie activity, patient satisfaction, stem survival and reoperations, and assessment of prosthesis-cement-bone radiolucencies, osteolysis, and femoral bone deficiencies.

RESULTS

Median patient age was 34 years (16-40) and follow-up was 14 years (mean 13, range 5-22). Stem survival to the endpoint revision for loosening was 100% and to the endpoint revision for any reason, excluding infection was 88% (95% confidence interval 78-98) at 16 years. No stem was revised for aseptic loosening. Nine stems were revised for other reasons. Radiographically, one stem was definitely loose at 16 years. The median patient Harris pain score improved from marked pain to no pain at latest follow-up. Patient activity level improved, albeit minimally, for 8 years after surgery. At latest follow-up, 98% of the patients remained satisfied with their surgery.

CONCLUSION

Primary THA with a cemented polished stem shows excellent results in young patients with pathology other than primary osteoarthritis. In addition, the stem design facilitates cement within cement exchange and therefore preservation of proximal femoral bone stock at revision surgery.

Revision Total Hip Arthroplasty Using the Cement-in-Cement Technique

The cement-in-cement technique is useful in the setting of revision total hip arthroplasty (THA), especially to gain acetabular exposure, change a damaged or loose femoral component, or change the version, offset, or length of a fixed femoral component. The goal of this retrospective study was to assess the clinical and radiographic characteristics of revision THA using the cement-in- cement technique. Between 1971 and 2013, a total of 63 revision THAs used an Omnifit (Osteonics, Mahwah, New Jersey) or Exeter (Howmedica, Mahwah, New Jersey) stem and the cement-in-cement technique at the senior author's institution. Aseptic loosening (74%) was the predominant preoperative diagnosis followed by periprosthetic fracture (14%), instability (8%), and implant fracture (6%). Mean clinical follow-up was 5.5±3.8 years. The Harris Hip Score had a statistically significant increase of 18.5 points (P<.001) after revision THA using the cement-in-cement technique. There were 13 returns to the operating room, resulting in an overall failure rate of 21%. Eleven (18%) cases required revision THA, but only 1 (2%) revision THA was for aseptic removal of the femoral component. All other femoral implants had no evidence of component migration, cement mantel fracture, or circumferential lucent lines at final follow-up. The patients who underwent cement-in-cement revision THA at the senior author's institution had good restoration of function but a high complication rate. [Orthopedics. 2017; 40(2):e348-e351.].

Cement-in-cement femoral component revision in the multiply revised total hip arthroplasty: results with a minimum follow-up of five years

AIMS

We present the clinical and radiological results at a minimum follow-up of five years for patients who have undergone multiple cement-in-cement revisions of their femoral component at revision total hip arthroplasty (THA).

PATIENTS AND METHODS

We reviewed the outcome on a consecutive series of 24 patients (10 men, 14 women) (51 procedures) who underwent more than one cement-in-cement revision of the same femoral component. The mean age of the patients was 67.5 years (36 to 92) at final follow-up. Function was assessed using the original Harris hip score (HHS), Oxford Hip Score (OHS) and the Merle D'Aubigné Postel score (MDP).

RESULTS

The mean length of follow-up was 81.7 months (64 to 240). A total of 41 isolated acetabular revisions were performed in which stem removal facilitated access to the acetabulum, six revisions were conducted for loosening of both components and two were isolated stem revisions (each of these patients had undergone at least two revisions). There was significant improvement in the OHS (p = 0.041), HHS (p = 0.019) and MDP (p = 0.042) scores at final follow-up There were no stem revisions for aseptic loosening. Survival of the femoral component was 91.9% (95% confidence intervals (CI) 71.5 to 97.9) at five years and 91.7% (95% CI 70 to 97) at ten years (number at risk 13), with stem revision for all causes as the endpoint.

CONCLUSION

Cement-in-cement revision is a viable technique for performing multiple revisions of the well cemented femoral component during revision total hip arthroplasty at a minimum of five years follow-up. Cite this article: Bone Joint J 2017;99-B:199-203.

Mid- and long-term results of femoral component revision using the cement-in-cement technique: Average 10.8-year follow-up study

BACKGROUND

Few reports are available on the long-term outcomes of femoral component revision by using the cement-in-cement technique. We report the mid- and long-term results of femoral component revision in total hip arthroplasty using the cement-in-cement technique.

METHODS

Between April 1996 and June 2009, 62 consecutive total hip arthroplasties with femoral component revision were performed in 57 patients by using the cement-in-cement technique. We retrospectively reviewed the cases with a follow-up period of at least five years. Three patients died, and two were lost to follow-up. Thus, 52 patients (57 hips), comprising 51 women and one man, were followed for average 10.8 years.

RESULTS

The mean Japanese Orthopaedic Association hip score improved from 57.6 points (range, 28-95 points) preoperatively to 79.8 points (range, 52-98 points) at one year postoperatively and to 77.4 points (range, 59-96 points) at the final follow up. Three revisions of the femoral component were necessary. One of the causes for the revision was a periprosthetic infection that occurred 20 months postoperatively. Another was aseptic loosening that occurred 99 months postoperatively and required revision of the acetabular component. The well-fixed femoral component was revised using the cement-in-cement technique at time of the acetabular revision. The third case was aseptic loosening of the femoral component that occurred 84 months postoperatively. The five-, 10-, and 15-year survival rates for the femoral re-revision due to any reason were 98.4%, 94.0%, and 94.0%, respectively.

CONCLUSION

Use of the cement-in-cement technique for revision total hip arthroplasty resulted in good mid- and long-term radiological and clinical outcomes.

A valuable technique for femoral stem revision in total hip replacement: The in-cement revision - A case series and technical note

Revision of a cemented femoral stem can be a challenging procedure. We present a series of cases utilising the "In-cement" revision, whereby the same size stem is introduced into the original cement mantle, without additional cementing. It requires a stable cement mantle in the correct version. We describe the technique and present a review of 23 revision total hip replacements performed over a 5 year period. At average follow-up of 67 months (12-128 months), the overall survivorship was 91.3% with no patient requiring re-revision for stem loosening or mechanical failure. Two patients required re-revision for infection and one of those patients is now deceased. No further operations were required in 21 patients. The "In-cement" revision can be a valuable technique for the revision arthroplasty surgeon. Early results suggest this is a safe and effective technique in the appropriate patient.

Management of femoral bone loss in revision total hip arthroplasty

Femoral bone loss is frequently encountered during revision total hip arthroplasty. The quality and quantity of remaining bone helps determine the best method for reconstruction. Extensively porous-coated cylindrical stems or titanium fluted tapered devices that achieve fixation in the diaphysis have both demonstrated excellent long-term survivorship. Titanium fluted tapered stems with a modular proximal body allow for more accurate leg length, offset, and version adjustments independent of the distal stem which may optimise hip biomechanics. Intraoperative fractures are more common with cylindrical stems and subsidence with tapered stems, particularly monoblock designs and in both dislocation continues to be one of the most common postoperative complications. In salvage situations in which an ectatic femoral canal is unable to support an uncemented device, impaction bone grafting, allograft-prosthetic composite, or a segmental proximal femoral replacement may be required.

Cement brand and preparation effects cement-in-cement mantle shear strength

Creating bi-laminar cement mantles as part of revision hip arthroplasty is well-documented but there is a lack of data concerning the effect of cement brand on the procedure. The aim of this study was to compare the shear strength of bi-laminar cement mantles using various combinations of two leading bone cement brands.Bi-laminar cement mantles were created using Simplex P with Tobramycin, and Palacos R+G: Simplex-Simplex (SS); Simplex-Palacos (SP); Palacos-Simplex (PS); and Palacos-Palacos (PP). Additionally, specimens were produced by rasping (R) the surface of the original mantle, or leaving it unrasped (U), leading to a total of eight groups (n = 10). Specimens were loaded in shear, at 0.1 mm/min, until failure, and the maximum shear strength calculated.The highest mean shear strength was found in the PSU and PSR groups (23.69 and 23.89 MPa respectively), and the lowest in the PPU group (14.70 MPa), which was significantly lower than all but two groups. Unrasped groups generally demonstrated greater standard error than rasped groups.In a further comparison to assess the effect of the new cement mantle brand, irrespective of the brand of the original mantle, Simplex significantly increased the shear strength compared to Palacos with equivalent preparation.It is recommended that the original mantle is rasped prior to injection of new cement, and that Simplex P with Tobramycin be used in preference to Palacos R+G irrespective of the existing cement type. Further research is needed to investigate more cement brands, and understand the underlying mechanisms relating to cement-in-cement procedures.

Revision total hip arthroplasty using cemented collarless double-taper femoral components at a mean follow-up of 13 years (8 to 20): an update

The outcome of 219 revision total hip arthroplasties (THAs) in 98 male and 121 female patients, using 137 long length and 82 standard length cemented collarless double-taper femoral stems in 211 patients, with a mean age of 72 years (30 to 90) and mean follow-up of six years (two to 18) have been described previously. We have extended the follow-up to a mean of 13 years (8 to 20) in this cohort of patients in which the pre-operative bone deficiency Paprosky grading was IIIA or worse in 79% and 73% of femurs with long and standard stems, respectively. For the long stem revision group, survival to re-revision for aseptic loosening at 14 years was 97% (95% confidence interval (CI) 91 to 100) and in patients aged > 70 years, survival was 100%. Two patients (two revisions) were lost to follow-up and 86 patients with 88 revisions had died. Worst-case analysis for survival to re-revision for aseptic loosening at 14 years was 95% (95% CI 89 to 100) and 99% (95% CI 96 to 100) for patients aged > 70 years. One additional long stem was classified as loose radiographically but not revised. For the standard stem revision group, survival to re-revision for aseptic loosening at 14 years was 91% (95% CI 83 to 99). No patients were lost to follow-up and 49 patients with 51 hips had died. No additional stems were classified as loose radiographically. Femoral revision using a cemented collarless double-taper stem, particularly with a long length stem, and in patients aged > 70 years, continues to yield excellent results up to 20 years post-operatively, including in hips with considerable femoral metaphyseal bone loss.

Stem compatibility for cement-in-cement femoral revision: an in vitro study

Cement-in-cement femoral component revision is a useful and commonly practised technique. Onerous and hazardous re-shaping of the original cement mantle is required if the new stem does not seat easily. Furthermore, without removing the entirety of the original cement mantle, the freedom to alter anteversion or leg length is difficult to predict preoperatively. We present data from in vitro experiments testing the compatibility of the top cemented stems according to UK registry figures (NJR 2013). This data augments preoperative planning by indicating which revision stems require minimal or no cement reshaping when being inserted into another stem's mantle. We also present the maximum shortening and anteversion that can be achieved without reshaping the original cement mantle.

Cement-in-cement femoral revisions using a specially designed polished short revision stem; 24 consecutive stems followed for five to seven years

Femoral cement-in-cement revisions are attractive if the cement bone mantle is well fixed. However, most available cemented stems are too long to fit in the existing cement mantle. We evaluated the medium-term outcomes of the 125 mm short tapered polished stem (Exeter Short Revision Stem (SRS)) with a 44 mm offset specifically designed to facilitate cement-in-cement revisions of hip arthroplasties. The Exeter SRS was clinically and radiographically evaluated in 24 consecutive femoral cement-in-cement revisions (11 men, 13 women) between July 2005 and February 2008 after a mean follow-up of six years (5-7). The mean age at operation was 67 years (54-83). No hip was lost to follow-up, but two patients (two hips) died. None of the deaths were related to the surgery. Kaplan Meier survival analysis was performed. Four femoral components (17%) were removed for septic loosening after a mean of 2.4 years (0.8-4.9). Three of these hips were revised again in a two-stage revision, and one was converted to a permanent excision arthroplasty. The probability of survival with re-revision for any reason was 82% (95% CI: 58-93) and survivorship with aseptic loosening as the endpoint was 100% at six years. There were no additional radiological failures. The Exeter Short Revision Stem is a valuable option for simplifying cement-in-cement revisions. Despite the short stem length, at mid-term there were no signs of instability or aseptic loosening.

The management of type B1 periprosthetic femoral fractures: when to fix and when to revise

The incidence of periprosthetic fractures around total hip arthroplasty is increasing as patient longevity rises and the number of patients with hip implants continues to grow. Type B1 periprosthetic femoral fractures are associated with a well-fixed stem and have traditionally been treated with internal fixation. However, there are a subset of these fractures which fare badly when internal fixation is undertaken, and revision of the femoral component to a long-stemmed implant may be more appropriate. We look at the traditional methods of fixation, and the evidence and indications for revision of these fractures.

Massive bone defect compromises postoperative cup survivorship of acetabular revision hip arthroplasty with impaction bone grafting

We evaluated 66 acetabular revision arthroplasties using cemented cup with impaction bone grafting (IBG) to detect the extent that bone defect affects the outcome. We defined the maximum acetabular defect distance (MADD), which indicates the greatest depth of the grafted layer. Cup survival analysis with aseptic loosening as the endpoint revealed that the "MADD≤20mm" group showed higher survivorship than the "MADD>20mm" group (95% vs. 74%, P=0.034), and that the simple-wall-defect group (none or one mesh used) showed higher survivorship than the complex-wall-defect group (two meshes used) (96% vs. 73%, P=0.044). A favorable indication for acetabular IBG reconstruction is cases in which those cups can be placed at≤20mm MADD with a simple wall defect.

Cement in cement revision of the femoral component using a collarless triple taper: a midterm clinical and radiographic assessment

This study describes the midterm clinical and radiological results of the cement in cement technique for the femur using a collarless triple taper. Radiographic assessment was made retrospectively from 44 patients at two time points. Clinical outcomes included the Oxford Hip Score, EQ5D and Self Reported Patient Satisfaction Scale. Implant and patient survival were also recorded. The mean clinical follow up period was 5years 3months and the radiological follow up 2years 10months. The mean OHS was 34, the mean EQ5D 0.814 and the mean SAPS 94. Kaplan-Meier survival with revision, as the end point was 95.2% at 11years with a survivorship of 76.5% with death as the end point. Cement in cement revision using a collarless triple tapered stem demonstrates promising results both clinically and radiologically at midterm follow up.

One-component revision in total hip arthroplasty: the fate of the retained component

The purpose of the present study was to evaluate the long-term outcome of the unrevised part in one-component total hip arthroplasty revision (index operation). Forty-four patients (46 hips) with a mean age of 58years at the time of the index operation were included. At the final follow-up, 4 of the 19 (21%) unrevised acetabular components and 6 of the 27 (22%) unrevised femoral components were subsequently revised at a mean time of 14 and 11years from the index operation, and 22 and 24years from the primary operation, respectively. We concluded that revision of a stable component is not justifiable on the basis of its long duration in use or non-ideal position or possible loosening on radiographs.

A modified technique to extract fractured femoral stem in revision total hip arthroplasty: A report of two cases

INTRODUCTION

The removal of well-fixed broken femoral component and cement mantle can be extremely demanding, time consuming and potentially damaging to the host bone. Different methods have been described to extract broken femoral stem yet this remains one of the most challenging prospect to the revision hip surgeon.

PRESENTATION OF CASE

The authors present two cases underwent a modified sliding cortical window technique utilising a tungsten carbide drill, Charnley pin retractor and an orthopaedic mallet to aid extraction of a fractured cemented femoral stem in revision total hip arthroplasty.

DISCUSSION

The modified technique offers a simple and controlled method in extracting a well fixed fractured cemented femoral stem. It has the advantage of retaining the cement mantle with subsequent good seal of the femoral cortical window secured with cable ready system. Furthermore, tungsten carbide drill bit and Charnley pin retractor are relatively readily available to aid the extraction of the broken stem. Finally, it yields the option of implanting a standard femoral stem and obviates the need for bypassing the cortical window with long revision femoral component.

CONCLUSION

Fractured femoral stem is a rare yet a complex and very demanding prospect to both patients and hip surgeons. The sliding cortical window technique utilising tungsten carbide drill and Charnley pin retractor is technically easy and most importantly; preserves host bone stock with cement-in-cement revision hip arthroplasty. We believe this technique can be added to the armamentarium of revision hip surgeon when faced with the challenge of extracting a fractured cemented femoral stem.

Cement-in-cement revision for selected Vancouver Type B1 femoral periprosthetic fractures: a biomechanical analysis

The aim of this study was to perform a biomechanical analysis of the cement-in-cement (c-in-c) technique for fixation of selected Vancouver Type B1 femoral periprosthetic fractures and to assess the degree of cement interposition at the fracture site. Six embalmed cadaveric femora were implanted with a cemented femoral stem. Vancouver Type B1 fractures were created by applying a combined axial and rotational load to failure. The femora were repaired using the c-in-c technique and reloaded to failure. The mean primary fracture torque was 117 Nm (SD 16.6, range 89-133). The mean revision fracture torque was 50 Nm (SD 16.6, range 29-74), which is above the torque previously observed for activities of daily living. Cement interposition at the fracture site was found to be minimal.

Revision total hip replacement using the cement-in-cement technique for the acetabular component

The technique of femoral cement-in-cement revision is well established, but there are no previous series reporting its use on the acetabular side at the time of revision total hip replacement. We describe the technique and report the outcome of 60 consecutive acetabular cement-in-cement revisions in 59 patients at a mean follow-up of 8.5 years (5 to 12). All had a radiologically and clinically well-fixed acetabular cement mantle at the time of revision. During the follow-up 29 patients died, but no hips were lost to follow-up. The two most common indications for acetabular revision were recurrent dislocation (46, 77%) and to complement femoral revision (12, 20%).

Of the 60 hips, there were two cases of aseptic loosening of the acetabular component (3.3%) requiring re-revision. No other hip was clinically or radiologically loose (96.7%) at the latest follow-up. One hip was re-revised for infection, four for recurrent dislocation and one for disarticulation of a constrained component. At five years the Kaplan-Meier survival rate was 100% for aseptic loosening and 92.2% (95% CI 84.8 to 99.6), with revision for any cause as the endpoint.

These results support the use of cement-in-cement revision on the acetabular side in appropriate cases. Theoretical advantages include preservation of bone stock, reduced operating time, reduced risk of complications and durable fixation.

Femoral bone is preserved using cemented polished stems in young patients

BACKGROUND

Techniques that ensure femoral bone preservation after primary THA are important in younger patients who are likely to undergo revision surgery.

QUESTIONS/PURPOSES

We examined femoral stem survival, bone deficiency at revision arthroplasty, and radiographic bone loss in hips implanted with a cemented polished double-taper stem in a cohort of patients younger than 55 years.

METHODS

We reviewed 197 hips (median patient age, 47 years; range, 16-54 years) after a minimum followup of 2 years (median, 7 years; range, 2-19 years) since primary THA. Clinically, we determined survival to major and minor stem revision and cases of bone deficiency requiring a long stem or impaction bone grafting or created by the need for femoral osteotomy at revision arthroplasty. Radiographically, we assessed stem loosening, femoral osteolysis, and femoral bone deficiency.

RESULTS

Stem survival to major revision for aseptic loosening was 100% at 13 years and for any reason was 97% (95% CI, 93-100%). At revision of seven stems, a long stem was used in one hip, a total femoral replacement in one hip and impaction bone grafting in one hip. No femoral osteotomies were required. Bone was preserved in four hips by cement-within-cement stem exchange. No stems were radiographically loose. Proximal osteolysis was present in 11% of femurs. Femoral bone deficiency was graded as Paprosky Type I (97%) or II (3%) and Endo-Klinik Grade 0 (79%) or I (21%).

CONCLUSIONS

Cemented polished taper stems have high survival at 13 years in young patients and enable femoral bone preservation for subsequent revision.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Shortening cemented femoral implants: an in vitro investigation to quantify exeter femoral implant rotational stability vs simulated implant length

The Exeter stems vary in length from 90 to 150 mm. The shorter stems generally have lower offsets. The purpose of this study was to determine if length of stem, with fixed offset, affected rotational stability. Mechanical testing was carried out on 10 implant-cement constructs with 2 loading profiles, rising from chair and stair climbing, at different simulated implant lengths using purpose-built apparatus. This paper presents a mechanism for clinically observed rotational stability and explains the mechanical characteristics required for rotational stability in Exeter femoral stems.

Factors affecting flexural strength in cement within cement revisions

Cement within cement revisions provide substantial benefits for conventional revision yet remains uncommon possibly because of the perceived weakness of the cement-cement interface. This study investigated the flexural strength of beams composed of 2 different cements, exploring the factors of pore size, fracture location, viscosity, and the surface roughness of the interface. We found no significant difference when comparing combinations of different cements (P = .30), varying pore sizes (P = .13), or surface roughness (P = .39). Differences in fracture locations and viscosity combinations approached statistical significance (P = .08 and .05, respectively). Our findings suggest strong bonding between cements at the interface, with other factors being more important causes of weakness. Thus, we recommend that the strength of the cement-cement interface should not be a factor when considering such revisions.

The effect of surface finish and interstitial fluid on the cement-in-cement interface in revision surgery of the hip

The mechanical performance of the cement-in-cement interface in revision surgery has not been fully investigated. The quantitative effect posed by interstitial fluids and roughening of the primary mantle remains unclear. We have analysed the strength of the bilaminar cement-bone interface after exposure of the surface of the primary mantle to roughening and fluid interference. The end surfaces of cylindrical blocks of cement were machined smooth (Ra = 200 nm) or rough (Ra = 5 μm) and exposed to either different volumes of water and carboxymethylcellulose (a bone-marrow equivalent) or left dry. Secondary blocks were cast against the modelled surface. Monoblocks of cement were used as a control group. The porosity of the samples was investigated using micro-CT. Samples were exposed to a single shearing force to failure.

The mean failure load of the monoblock control was 5.63 kN (95% confidence interval (CI) 5.17 to 6.08) with an estimated shear strength of 36 MPa. When small volumes of any fluid or large volumes were used, the respective values fell between 4.66 kN and 4.84 kN with no significant difference irrespective of roughening (p > 0.05). Large volumes of carboxymethylcellulose significantly weakened the interface. Roughening in this group significantly increased the strength with failure loads of 2.80 kN (95% CI 2.37 to 3.21) compared with 0.86 kN (95% CI 0.43 to 1.27) in the smooth variant. Roughening of the primary mantle may not therefore be as crucial as has been previously thought in clinically relevant circumstances.

Revision total hip arthroplasty: the femoral side using cemented implants

Advances in surgical technique and implant technology have improved the ten-year survival after primary total hip arthroplasty (THA). Despite this, the number of revision procedures has been increasing in recent years, a trend which is predicted to continue into the future. Revision THA is a technically demanding procedure often complicated by a loss of host bone stock which may be compounded by the need to remove primary implants. Both cemented and uncemented implant designs are commonly used in the United Kingdom for primary and revision THA and much controversy still exists as to the ideal method of stem fixation. In this article we discuss revision of the femur using cemented components during revision THA. We focus on three clinical scenarios including femoral cement-in-cement revision where the primary femoral cement-bone interface remains well fixed, femoral cement-in-cement revision for peri-prosthetic femoral fractures, and femoral impaction grafting. We discuss the clinical indications, surgical techniques and clinical outcomes for each of these procedures.

Impaction bone grafting for acetabular reconstruction: mean 5.5-year results in Japanese patients

INTRODUCTION

We performed a retrospective outcome study on 23 consecutive acetabular reconstructions involving impaction bone grafting in Japanese patients.

METHOD

Two hips had cavitary defects, and 21 hips had combined segmental and cavitary defects. The mid-term follow-up was performed at a mean of 5.5 years postoperatively. The mean Merle d'Aubigné and Postel hip score had improved from 11.5 to 15.7 points at the final follow-up. Two hips showed migration at 30 months after surgery, and one of these was a candidate for re-revision due to symptomatic cup migration.

RESULTS

The Kaplan-Meier survival rate of the cup, with loosening and re-operation as the end points, was 91.3 and 95.7% at 5 years, respectively.

CONCLUSION

Acetabular impaction bone grafting is a reproducible technique in which surgeons should strictly follow the recommended technical procedure.

Femoral stem displacement during closed reduction of a dislocated bipolar hemiarthroplasty of the hip

This article describes a case of femoral stem displacement during closed reduction of a redislocated bipolar hemiarthroplasty of the hip in a 72-year-old woman who had undergone bipolar hemiarthroplasty using a polished, tapered cemented femoral stem. The polished, tapered cemented femoral stem is vulnerable to displacement when exposed to traction forces. Six days after bipolar hemiarthroplasty, the patient experienced her first dislocation, and immediate reduction of the dislocated hip was easily achieved. However, on the ninth postoperative day, redislocation occurred, and this time, reduction was not achieved. Subsequent radiographs revealed an unreduced state with posterosuperior dislocation of the hip and dissociation of the femoral stem at the cement-stem interface with proximal migration. Open reduction was then performed, and it was noted that the bipolar prosthesis had dislocated posterosuperiorly, the neck of the femoral stem was incarcerated between the short external rotators, and the femoral stem had migrated proximally by approximately 8 cm. The femoral stem was repositioned by freeing it from the short external rotators and gently tapping it into the cement mantle. Our surgical solution is questionable, because the stability of the stem is likely to be inadequate. According to the established study, no difference in stuffiness was observed before extraction and after reinsertion, which supports the surgical solution we chose. Pre-reduction analysis should be conducted to determine the cause and status of a dislocation, and open reduction should be performed if closed reduction fails when treating dislocated bipolar hemiarthroplasty patients.

A prospective study of hip revision surgery using the Exeter long-stem prosthesis: function, subsidence, and complications for 57 patients

Background

The long-stem Exeter femoral component is commonly used in revision hip surgery. Subsidence of the femoral stem in primary hip arthroplasty has been studied extensively, but much less is known about its significance in revision surgery. This prospective study examined the relationship between radiological subsidence, Western Ontario and McMaster (WOMAC) osteoarthritis index pain score, patient satisfaction and complication rates for the long-stem Exeter hip prosthesis.

Materials and methods

Data was prospectively collected for a single-surgeon series of 96 patients undergoing revision surgery with a mean follow-up period of 36 months. Pre- and post-operative clinical evaluation was carried out using the validated WOMAC osteoarthritis index. Radiographic evaluation was carried out on magnification-adjusted digital radiographic images.

Results

Data from 57 patients were analysed. The mean rate of subsidence recorded was 0.43 mm/year, with a mean total subsidence of 0.79 mm [95% confidence interval (CI) 0.57–1.01] at 36.3 months. There was no correlation between subsidence and post-operative WOMAC score, complication rate or patient satisfaction. There was a statistically significant reduction between pre-operative and post-operative WOMAC scores, with means of 33.5 and 10.7, respectively (P < 0.001), and high patient satisfaction.

Conclusion

Our subsidence rates for long-stem revision femoral components are lower than the published data but demonstrate the same plateau. Radiographic subsidence does not appear to relate to functional outcome or complication rates in our data.

Cement-in-cement stem revision for Vancouver type B periprosthetic femoral fractures after total hip arthroplasty. A 3-year follow-up of 23 cases

BACKGROUND AND PURPOSE

Revision surgery for periprosthetic femoral fractures around an unstable cemented femoral stem traditionally requires removal of existing cement. We propose a new technique whereby a well-fixed cement mantle can be retained in cases with simple fractures that can be reduced anatomically when a cemented revision is planned. This technique is well established in femoral stem revision, but not in association with a fracture.

PATIENTS AND METHODS

We treated 23 Vancouver type B periprosthetic femoral fractures by reducing the fracture and cementing a revision stem into the pre-existing cement mantle, with or without supplementary fixation.

RESULTS

3 patients died in the first 6 months for reasons unrelated to surgery. In addition, 1 was too frail to attend follow-up and was therefore excluded from the study, and 1 patient underwent revision surgery for a nonunion. The remaining 18 cases all healed with radiographic union after an average time of 4.4 (2-11) months. There was no sign of loosening or subsidence of the revision stems within the old cement mantle in any of these cases at the most recent follow-up after an average of 3 (0.3-9) years.

INTERPRETATION

Our results support the use of the cement-in-cement revision in anatomically reducible periprosthetic fractures with a well-preserved pre-existing cement mantle. This technique is particularly useful for the elderly patient and for those who are not fit for prolonged surgical procedures.

In vitro cyclic testing of the Exeter stem after cement within cement revision

Cement-within-cement (C-C) revision arthroplasty minimizes the complications associated with removal of secure polymethylmethacrylate. Failure at the interfacial region between new and old cement mantles remains a theoretical concern. This article assesses the cyclic fatigue properties of bilaminar cement mantles after C-C revision in vitro with the Exeter stem. Seven Exeter stems were cemented into Sawbone femurs and removed, and new undersized stems were cemented into the preserved mantle. The new constructs were loaded for 1,000,000 cycles at body temperature. Cement mantles were inspected postcycling. In no case was there delamination or failure of the cement mantle. The findings support the hypothesis that use of a thin revision cement mantle in conjunction with a polished double-tapered stem is not detrimental to the overall success of the implant. In the presence of a secure cement-bone interface in suitable patients, we recommend C-C revision techniques using double-tapered polished femoral stems.

[Cement-in-cement hip revision with a long-stemmed femoral component]

Revision hip surgery often requires individualized techniques and implants. We report on a case of failed femoral revision in an extensively cemented femur with a concomitant proximal and dorsal femoral bone defect. We advocate the clinically effective revision procedure of antegrade drilling of the stable cement mantle and use of a cemented long-stemmed femoral component. This cement-in-cement revision technique is discussed along with the pertinent literature.

The Exeter Universal cemented femoral component at 15 to 17 years

The first 325 Exeter Universal stems (309 patients) implanted at the originating centre were inserted between March 1988 and February 1990 by a group of surgeons with differing experience. In this report we describe the clinical and radiological results at a mean of 15.7 years (14.7 to 17.3) after operation with no loss to follow-up. There were 97 patients (108 hips) with replacements still in situ and 31 (31 hips) who had undergone a further procedure. With an endpoint of revision for aseptic loosening, the survivorship at 17 years was 100% and 90.4% for the femoral and acetabular component, respectively. The mean Merle D’Aubigné and Postel scores at review were 5.4 (sd 0.97) for pain and 4.5 (sd 1.72) for function. The mean Oxford score was 38.4 (sd 9.8) (0 to 48 worst-to-best scale) and the mean combined Harris pain and function score was 73.2 (sd 16.9). Radiological review showed excellent preservation of bone stock in the proximal femur and no failures of the femoral component.

Revision of the cemented femoral stem using a cement-in-cement technique

The removal of well-fixed bone cement from the femoral canal during revision of a total hip replacement (THR) can be difficult and risks the loss of excessive bone stock and perforation or fracture of the femoral shaft. Retaining the cement mantle is attractive, yet the technique of cement-in-cement revision is not widely practised. We have used this procedure at our hospital since 1989. The stems were removed to gain a better exposure for acetabular revision, to alter version or leg length, or for component incompatibility.

We studied 136 hips in 134 patients and followed them up for a mean of eight years (5 to 15). A further revision was required in 35 hips (25.7%), for acetabular loosening in 26 (19.1%), sepsis in four, instability in three, femoral fracture in one and stem fracture in one. No femoral stem needed to be re-revised for aseptic loosening.

A cement-in-cement revision of the femoral stem is a reliable technique in the medium term. It also reduces the risk of perforation or fracture of the femoral shaft.

The polished tri-tapered stem for cement-in-cement revision hip arthroplasty, a reliable and reproducible technique?

The object of this study was to determine the short to medium term outcome of cementing a highly polished tapered implant into the old cement mantle once damaged cement is removed at the time of revision hip surgery. A consecutive series of 36 patients underwent c-stem cement-in-cement revision hip arthroplasty between June 2000 and April 2006. The primary outcome measure was the validated shortened Western Ontario and McMaster Universities (WOMAC) score, secondary outcomes were the Orthowave company patient satisfaction survey, radiological analysis, and general complications. The follow-up period was between 12 and 84 months (average 48.86 months). The mean post op WOMAC score at latest follow-up was 10.89 (0 to 29). Two patients died with their hip in situ. Two patients had radiological signs of prosthesis loosening on follow-up. Complications included: one sacral plexus palsy which had a partial recovery and one intra-operative periprosthetic fracture. One patient underwent cup revision for recurrent dislocation. Cement within cement revision hip arthroplasty using a highly polished tapered stem in the short to medium term provides satisfactory functional outcomes and is associated with a low complication rate and good survivorship.

Clinical and radiological evaluation of revision hip arthroplasty using the cement-in-cement technique

We reviewed 44 consecutive revision hip replacements in 38 patients performed using the cement-in-cement technique. All were performed for acetabular loosening in the presence of a well-fixed femoral component. The mean follow-up was 5.1 years (2 to 10.1). Radiological analysis at final follow-up indicated no loosening of the femoral component, except for one case with a continuous radiolucent line in all zones and peri-prosthetic fracture which required further revision. Peri-operative complications included nine proximal femoral fractures (20.4%) and perforation of the proximal femur in one hip. In five hips wiring or fixation with a braided suture was undertaken but no additional augmentation was required. There was an improvement in the mean Japanese Orthopaedic Association score from 55.5 (28 to 81) pre-operatively to 77.8 (40 to 95) at final follow-up (p < 0.001). Revision using a cement-in-cement technique allows increased exposure for acetabular revision and is effective in the medium term. Further follow-up is required to assess the long-term results in the light of in vitro studies which have questioned the quality of the cement-in-cement bond.