WHAT MUST BE A WELL-CEMENTED

PROSTHESIS?

Graham Gie FRCSEd(Orth)

PEOC

Exeter

WHAT MUST BE A WELL- CEMENTED PROSTHESIS?

1. Surgical Technique

2. Type of Implant

A good cemented THA:

A good cemented THA:

Conducted by a skilled surgeon

A good cemented THA:

Conducted by a skilled surgeon

Through an adequate exposure with consideration for bony & soft tissue

structures

A good cemented THA:

Conducted by a skilled surgeon

Through an adequate exposure with consideration for bony & soft tissue

structures

Minimising complications

A good cemented THA:

Conducted by a skilled surgeon

Through an adequate exposure with consideration for bony & soft tissue

structures

Minimising complications

Using modern cementing techniques & instrumentation

A good cemented THA:

Conducted by a skilled surgeonThrough an adequate exposure with consideration for bony & soft tissue

structuresMinimising complications

Using modern cementing techniques & instrumentation

And a tried and tested prosthesis

A good cemented THA:

Conducted by a skilled surgeon

Who performs the procedure frequently

Skilled Surgeon?

Gifted?Performs the procedure

frequently

PRACTICE MAKES PERFECT

Exposure considering bony & soft tissues

Reduce soft tissue dissectionPost approach preserving

piriformisDon’t take trochanter off

Repair soft tissues

Minimising Complications

Avoid trochanteric problemsReduce dislocations

Avoid sepsis

Using modern techniques & instrumentation

Acetabulum

Femur

ACETABULUMCircumferential view

ACETABULUMCircumferential view

Exposure of cancellous bone

ACETABULUMCircumferential view

Exposure of cancellous bone

Rim cutter

RIM CUTTER

ACETABULUMCircumferential view

Exposure of cancellous bone

Rim Cutter

High pressure lavage & dry

Primary Exeter Cemented Prosthesis : Socket Lavage

ACETABULUMCircumferential view

Exposure of cancellous bone

Rim Cutter

High pressure lavage & dry

Iliac suction

Iliac Sucker

ACETABULUMCircumferential view

Exposure of cancellous bone

Rim Cutter

High pressure lavage & dry

Ilial suction

Cement pressurisation

Primary Exeter Cemented Prosthesis : Pressurizing Cement

Primary Exeter Cemented Prosthesis : New Cup Insertion

ACETABULUMCircumferential view

Exposure of cancellous boneRim Cutter

High pressure lavage & dryIlial suction

Cement pressurisation Flanged socket, highly crosslinked

poly

Primitive technique Contemporary technique

The Socket

FEMUR

Good exposure

FEMUR

Good exposureClean & Dry Canal

FEMUR

Good exposureClean & Dry Canal

Gun insertion of cement

FEMUR

Good exposureClean & Dry Canal

Gun insertion of cementPressurisation

FEMUR

Good exposureClean & Dry Canal

Gun insertion of cementPressurisation

Delayed insertion of a polished stem, collarless &

double-tapered

FEMUR

Primary Exeter Cemented Prosthesis : Femoral Cementing

Post-op 11yrs

Post-op 12yrs

Cemented THA Cemented THA with a polished with a polished

stem stem – – up to 33 years up to 33 years

follow-upfollow-up

Survivorship curve of the original polished Exeter stems -1970-75: end point revision for aseptic stem loosening

Years since operation

SurvIvorshIp

%

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

0to1

1to2

2to3

3to4

4to5

5to6

6to7

7to8

8to9

9to10

10to11

11to12

12to13

13to14

14to15

15to16

16to17

17to18

18to19

19to20

20to21

21to22

22to23

23to24

24to25

25to26

26to27

27to28

28to29

29to30

30to31

31to32

32to33

Survivorship 93.14%: 95% C.L. 74.39-100%

Survivorship curve of the original polished Exeter stems 1970-75: patients under age 60 at operation. End point revision for

aseptic stem loosening

Years since operation

SurvIvorshIp

%

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Survivorship 87.22%: 95%CL 54.55 – 100% (68 cases)

Years since operation

SurvIvorshIp

%

Original cups 1970-75; survivorship with end-point revision for aseptic cup loosening

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

0to1

1to2

2to3

3to4

4to5

5to6

6to7

7to8

8to9

9to10

10to11

11to12

12to13

13to14

14to15

15to16

16to17

17to18

18to19

19to20

20to21

21to22

22to23

23to24

24to25

25to26

26to27

27to28

28to29

29to30

30to31

31to32

32to33

Survivorship 72.45%: 95%CL 39.12-100%

A 12-17 YEAR SURVIVORSHIP STUDY OF THE

EXETER UNIVERSAL

CEMENTED STEM

A 12-17 YEAR SURVIVORSHIP STUDY OF THE

EXETER UNIVERSAL

CEMENTED STEM

Exeter Universal Series: Survivorship with endpoint re-operation for aseptic stem loosening;

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 to 7 7 to 8 8 to 9 9 to10

10 to11

11 to12

12 to13

13 to14

14 to15

15 to16

16 to17

Years since operation

Surv

ivor

ship

- % 100% stem survival at 10 – 17

yrs

CEMENTED EXETER THA IN

PATIENTS AGED 50 OR

LESS

CEMENTED EXETER THA IN

PATIENTS AGED 50 OR

LESS

O

10 to 17 year follow-up

10 to 17 year follow-up

DETAILS OF YOUNG HIP REVIEW

Patients 107Bilateral arthroplasties 23

TOTAL No. HIPS: 130

Follow-up: Range: 10 – 17 years Average: 12.5 years

No case lost to follow-up

Died of unrelated causes: 7 hips

DETAILS OF YOUNG HIP

REVIEW

Mean age at Sx 42yrs

12 REVISIONS12 REVISIONSLOOSE CUPS 9 (6.8%)CUP FOR LYSIS 1RECURRENT DISL 1INFECTION 1

LOOSE STEMS 0

LOOSE CUPS 9 (6.8%)CUP FOR LYSIS 1RECURRENT DISL 1INFECTION 1

LOOSE STEMS 0

Exeter Universal Series: Survivorship with endpoint re-operation for aseptic stem loosening; (95% confidence

limits obtained using the Rothman equation).

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Years since operation

Sur

vivo

rshi

p - %

WHAT MAKES A WELL-CEMENTED THA?

Excellent technique

with a tried & tested prosthesis

Thank you Thank you for your for your attentionattention