Aims

Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique.

The removal of all prosthetic material and a two-stage revision procedure is the established standard management of an infected total hip replacement (THR). However, the removal of well-fixed femoral cement is time-consuming and can result in significant loss of bone stock and femoral shaft perforation or fracture. We report our results of two-stage revision THR for treating infection, with retention of the original well-fixed femoral cement mantle in 15 patients, who were treated between 1989 and 2002. Following partial excision arthroplasty, patients received local and systemic antibiotics and underwent reconstruction and re-implantation at a second-stage procedure, when the infection had resolved.

The mean follow-up of these 15 patients was 82 months (60 to 192). Two patients had positive microbiology at the second stage and were treated with six weeks of appropriate antibiotics; one of these developed recurrent infection requiring further revision. Successful eradication of infection was achieved in the remaining 14 patients.

We conclude that when two-stage revision is used for the treatment of peri-prosthetic infection involving a THR, a well-fixed femoral cement mantle can be safely left in situ, without compromising the treatment of infection. Advantages of this technique include a shorter operating time, reduced loss of bone stock and a technically more straightforward second-stage procedure.

Although cement in cement acetabular revision is a recognised option in the presence of a well-fixed cement mantle, partial cement mantle retention is not normally recommended or practiced. However, when revising a cemented acetabular cup it is not infrequent to be faced with loose superolateral cement but well-fixed medial cement. Removal of the well-fixed cement can be time consuming and destructive. An alternative would be to retain this cement and incorporate it into the reconstruction. This study assesses the practice and results of partial cement mantle retention (PCR) at acetabular revision. We retrospectively identified a cohort of 28 hips in 26 patients using the PCR technique from 1. st. January 2000 to 1. st. January 2013. This represented 3.3% of cup revisions where a cemented cup was used. The area of cement loss was reconstructed in one of three ways: re-cementing into drill holes (6 cases); impaction grafting of the defect (8 cases); or use of a trabecular metal wedge (14 cases). 24 hips had a minimum 2-year follow up (mean 6 years). There were no subsequent revisions for aseptic loosening. One acetabulum was later revised for dislocation and X-rays were lost in one patient leaving 22 patients with x-ray available and retained implants. Two of these cases showed progression of lucent lines, which were not clinically significant. Retaining well-fixed medial cement during socket revision appears to be a reasonable reconstruction option in carefully selected cases

We have compared the survival of 67 revision arthroplasties of the knee undertaken for aseptic loosening with and without the retention of a secure, cemented femoral component. All the patients had undergone a single primary procedure at a mean of nine years previously. In group I (25 knees) the original femoral component was secure and was retained. There were no abrasions or osteolysis. The knees were stable, normally aligned, with minimal bone loss. In group II 42 knees did not fulfil these criteria and underwent revision of both components. The mean follow-up was four years. Re-revision for loosening was required in seven knees (28%) in group I and three (7%) in group II (p < 0.01). The remaining knees function well with Knee Society scores averaging 84/69 and no radiological evidence of osteolysis. When revising cemented implants, retention of a secure femoral component cannot be recommended even when conditions appear to be suitable