Recent NICE guidance recommends use of a well proven cemented femoral stem for hip hemiarthroplasty in management of fractured neck of femur. The Exeter Trauma Stem (ETS) has been designed based on the well proven Exeter hip stem. It has a double taper polished stem design, proclaimed to share geometry and surface finish with the Exeter hip. This study investigated the surface finish of the two stems in order to investigate the hypothesis that they were different. Two ETS and two Exeter stems were examined using a profilometer with a sensitivity of one nanometer. Macroscopic visual inspection showed that the two Exeter stems had significantly smoother surface finish than the ETS stems. The roughness average (RA) values on the ETS stems were approximately an order of magnitude higher than those of the Exeter stems, mean of 0.235μm compared with 0.025μm (p<0.0001). This difference in surface finish has implications for the biomechanical functioning of the stem. Previous change of the Exeter stem to a matt surface-finish in 1976 resulted in a significant increase in stem failure rates and an understanding of the importance of the polished surface-finish in order to function within a taper-slip philosophy. By changing the surface finish in the ETS stem, longevity of the implant may similarly be affected. Clinical results have yet to be published demonstrating this. We recommend the manufacturer reconsiders the surface finish of the ETS stem to ensure it functions as well as the Exeter primary stem with which it shares a design philosophy

A complete cement mantle is important for the longevity of a total hip replacement. In the minimally-invasive direct anterior approach used at the Innsbruck University hospital, the femoral component has to be inserted into the femoral canal by an angulated movement. In a cadaver study, the quality and the extent of the cement mantle surrounding 13 Exeter femoral components implanted straight through a standard anterolateral transgluteal approach were compared with those of 13 similar femoral components implanted in an angulated fashion through a direct anterior approach. A third-generation cementing technique was used. The inner and outer contours of the cement mantles was traced from CT scans and the thickness and cross-sectional area determined. In no case was the cement mantle incomplete. The total mean thickness of the cement mantle was 3.62 mm (95% confidence interval 3.59 to 3.65). The mean thickness in the group using the minimally-invasive approach was 0.16 mm less than that in the anterolateral group. The distribution of the thickness was similar in the two groups. The mean thickness was less on the anteromedial and anterolateral aspect than on the posterior aspect of the femur. There is no evidence that the angulated introduction of Exeter femoral components in the direct anterior approach in cadavers compromises the quality, extent or thickness of the cement mantle

The Exeter Stem (Howmedica, UK) has been in use for over 35 years. Over the years it has undergone several modifications with the most recent being a highly polished, tapered stem in 1986. The manufacturers quote a rate of 0.0006%. In the current literature there are 16 (or less) instances of fractures of the Orthinox stem. We present a case of fracture of an Orthinox Exeter Stem 9 years after insertion. Our patient, BB, presented, aged 62, with symptoms & signs consistent with OA right hip. THR was performed through a lateral approach utilising a trochanteric osteotomy. A size 0 37.5 stem was inserted. Radiographs were very satisfactory. She suffered a post operative DVT/PTE from which she recovered uneventfully. She was independently mobile at 6 month review and was discharged at the 2 year stage pain free. Aged 71, BB presented to outpatient clinic with a several month history of generalised groin pain. She had a Trendelenberg gait. Considerable pain was experienced on axial compression of the limb. Radiographs revealed a midstem fracture with cement loosening proximally. No trauma was reported. She underwent revision surgery through a posterior approach. Acetabular component was rigidly fixed. This was revised to a pressfit Trident (Zimmer, UK) cup with screws & polyethylene liner. An extended trochanteric osteotomy was used to remove the broken stem. An uncemented Restoration (Stryker, UK) stem was inserted with a 28mm head. Post-operative recovery was unremarkable and at 6 months osteotomy has healed. The stem was sent to Stryker UK Laboratories for analysis. They reported the stem broke in fatigue with the origin on the antero-lateral surface. No material or manufacturing defects seen. Dimensionally correct. Fracture may be due to abnormal bending stresses secondary to proximal loosening and firm distal fixation. Our case demonstrates a set of circumstances that led to inevitable fatigue and stem fracture. The method of failure should reinforce the radiograph appearances that may cause concern or be acted upon

Femoral stem varus has been associated with poorer results. We report the incidence of varus/valgus malalignment of the Exeter polished, double taper design in a multicentre prospective study. The surgical outcomes at a minimum of five year and complication rates are also reported. A multicentre prospective study of 987 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and femoral stem malalignment. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of dislocation and revision. The incidence of varus and valgus malignment were 7.1% and 2.6% respectively. There was no significant difference in OHS between neutral and malaligned femoral stems at 5 years (neutral, mean = 40.2; varus, mean 39.3, p = 0.465; valgus, mean = 40.9, p = 0.605). There was no significant difference in dislocation rate between the groups (p = 0.66). There was also no significant difference in revision rate (p = 0.34). This study provides evidence that the Exeter stem is extremely tolerant of varus and valgus malalignment, both in terms of outcome and complication rate

The Exeter Trauma Stem (ETS) is a monoblock unipolar prosthesis currently in use throughout various orthopaedic departments. It can be a useful procedure for specialty trainees in developing modern cementation techniques in hip arthroplasty. We propose that in order for this procedure to be a valid training tool that, as well as having a standardized surgical approach and operative technique, outcomes should be easily assessed and should be similar if performed by either a trainee or consultant. All ETS procedures carried out at our institution from January 2009 until September 2011 were reviewed retrospectively. Patient demographics and operative details were recorded from patient notes. Radiographic evaluation involved the Barrack cementation grading system, Dorr's criteria, stem alignment and leg length measurement. There was no significant difference in operative time between ETS performed by consultant or by specialty trainee. On postoperative x-ray, cement mantles were Barrack grade A or B in 55.6% (trainees) versus 61.9% (consultants). Stem alignment was neutral in 50% and varus in 50% of cases for trainees, versus 28.6% and 71.4% of cases for consultants. In total, 69.2 % of patients had lengthening of the operated limb with a mean increase of 10.4mm (2–25) for trainees and 9.3mm (2–18) for consultants. Both trainees and consultants can attain a good cement mantle. However, from our results stem alignment is less accurate by trainees with half being placed in varus. Our results highlight the difficulty of obtaining correct leg length positioning with the ETS with trainees and consultants having similar discrepancies. The ETS is a useful procedure for orthopaedic trainees to attain adequate skills in modern cementation techniques with similar post-operative radiographic outcomes to consultants. The tendency for trainees to be less accurate with stem positioning could be improved with supervision or careful pre-operative templating

Exeter Trauma Stem (ETS) is one of the most common implants used for treating displaced intracapsular hip fractures in the UK. We previously performed a radiographic audit of these implants which showed good placement was difficult. This was in particular relation to leg length discrepancy (LLD). This study reviewed the clinical outcomes of these patients, in particular looking at the relation of leg length discrepancy to outcome. We performed a clinical review of patients at 3 months and 1 year post ETS for hip fracture. Oxford hip score (OHS), Trendelenberg test, Visual Analogue Score (VAS) and walking aids required were recorded. Leg length discrepancy was determined radiographically on initial post op X-ray. This was recorded as Even (+/− 5mm), 6-10mm Long and >10mm long. Seventy-two patients were reviewed at 3 months and 21 at 1 year. Mean VAS was 1.6. At 3 months 66% were Trendelenberg positive. Of those Trendelenberg positive at 3 months only 42% remained positive at 1 year. Mean OHS at 3months and 1 year was 30.8 and 32.1 respectively. On radiographic review 38 implants were Even, 24 were 6-10mm Long and 10 implants were >10mm Long. There was no correlation between leg length discrepancy and either VAS or Trendelenberg test. 45 patients ambulated independently pre-op. Of these only 8 ambulated independently post-op, 18 used a stick and 11 a Zimmer frame. There was no correlation between post operative leg length discrepancy and either Visual Analogue Score, OHS or Trendelenberg test. Mean pain score was very low. There was however almost 10% of patients with a VAS greater than 6. 80% of patients dropped one ambulatory level post-op, this is consistent with previous studies. The ETS provides good pain relief with a low complication rate in the vast majority of patients

This study compared the pullout forces of the initial implantation and the “cement-in-cement” revision technique for short and standard-length (125 mm vs. 150 mm) Exeter. ®. V40 femoral stems used in total hip arthroplasty (THA). The idea that the pullout force for a double taper slip stem is relative to the force applied to the femur and that “cement-in-cement” revision provides the same reproduction of force. A total sample size of 15 femoral stems were tested (Short, n = 6 and Standard, n = 9). 3D printed fixtures for repeatable sample preparation were used to minimize variance during testing. To promote stem subsidence and to simulate an in vivo environment, the samples were placed in an incubator at 37°C at 100% humidity and experienced a constant compressive loading of 1335 N for 14 days. The samples underwent a displacement-controlled pullout test. After the initial pullout test, “cement-in-cement” revision will be performed and tested similar to the initial implantation to observe the efficacy of the revision technique. To compare the pullout forces between the two groups, a Kruskal-Wallis test using a significance level of 0.05 was conducted. The mean maximum pullout force for the short and standard-length femoral stems were 3939 ± 1178 N and 5078 ± 1168 N, respectively. The Kruskal-Wallis test determined no statistically significant difference between the two groups for the initial implantation (p = 0.13). The “cement-in-cement” revision pullout force will be conducted in future testing. This study demonstrated the potential use of short stem designs for THA as it provides similar levels of fixation as the standard-length femoral stem. The potential benefits for using a short stem design would be providing similar load transfer to the proximal femur, preserving proximal metaphyseal femoral bone in primary replacement, and reducing the invasiveness during revision

Abstract. Objectives. The fidelity of a 3D model created using image segmentation must be precisely quantified and evaluated for the model to be trusted for use in subsequent biomechanical studies such as finite element analysis. The bones within the ankle joint vary significantly in size and shape. The purpose of this study was to test the hypothesis that the accuracy and reliability of a segmented bone geometry is independent of the particular bone being measured. Methods. Computed tomography (CT) scan data (slice thickness 1 mm, pixel size 808±7 µm) from three anonymous patients was used for the development of the ankle geometries (consisting of the tibia, fibula, talus, calcaneus, and navicular bones) using Simpleware Scan IP software (Synopsys, Exeter, UK). Each CT scan was segmented 4 times by an inexperienced undergraduate, resulting in a total of 12 geometry assemblies. An experienced researcher segmented each scan once, and this was used as the ‘gold standard’ to quantify the accuracy. The solid bone geometries were imported into CAD software (Inventor 2023, Autodesk, CA, USA) for measurement of the surface area and volume of each bone, and the distances between bones (tibia to talus, talus to navicular, talus to calcaneus, and tibia to fibula) were carried out. The intra-class coefficient (ICC) was used to assess intra-observer reliability. Bland Altman plots were employed as a statistical measure for criteria validity (accuracy) [1]. Results. The average ICC score was 0.93, which is regarded as a high reliability score for an inexperienced user. The talus to navicular and talus to tibia separations, which had the smallest distances, showed a slight decrease in reliability and this was observed for all separations shorter than 2 mm. According to the Bland-Altman plots, more than 95% of the data points were inside the borders of agreement, which is an excellent indication of accuracy. The bias percentage (average error percentage) varied between 1% and 4% and was constant across all parameters, with the proportion rising for short distance separations. Conclusions. The current study demonstrates that an inexperienced undergraduate, with access to software manuals, can segment an ankle CT scan with excellent reliability. The present study also concluded that all five bones were segmented with high levels of accuracy, and this was not influenced by bone volume or type. The only factor found to influence the reliability was the magnitude of distance between bones, where if this was smaller than 2 mm it reduced the reliability, indicating the influence of CT scan resolution on the segmentation reliability. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Studies using roentgen stereophotogrammetric analysis (RSA) have shown that the femoral components of cemented total hip replacements (THR) migrate distally relative to the bone, but it is not clear whether this occurs at the cement-implant or the cement-bone interface or within the cement mantle. Our aim was to determine where this migration occurred, since this has important implications for the way in which implants function and fail. Using RSA we compared for two years the migration of the tip of the stem with that of the cement restrictor for two different designs of THR, the Exeter and Charnley Elite. We have assumed that if the cement restrictor migrates, then at least part of the cement mantle also migrates. Our results have shown that the Exeter migrates distally three times faster than the Charnley Elite and at different interfaces. With the Exeter migration was at the cement-implant interface whereas with the Charnley Elite there was migration at both the cement-bone and the cement-implant interfaces

Introduction. There is much current debate concerning wear and corrosion at the taper junctions of large head total hip replacements, particularly metal-on-metal hips. Is such damage a modern concern or has it always occurred in total hip replacement but not previously noted. To investigate this five explanted V40 Exeter femoral stems (Stryker Howmedica) were obtained following revision surgery at a single centre. In all cases, the 24–26 mm femoral heads were still attached. Hypothesis. In conventional ‘small head’ modular hip prostheses such as the Exeter, negligible wear and corrosion is seen at the taper junction of explanted devices. Methods. The articulating surface and the taper junction of each femoral heads was measured using a Mitutoyo LEGEX322 co-ordinate measuring machine (CMM) In each case a wear map was generated and the wear volume from the contact surface was calculated using a bespoke MATLAB program. The accuracy of such measurements has been previously shown to be within 0.5mm3. Results. Wear analysis of the articulating surfaces found unworn surfaces with each femoral head having less than 1 mm. 3. volumetric wear. All tapers had minimal wear with volumetric wear of less than 0.5 mm. 3. . Discussion and Conclusion. The wear volumes measured fall within the CMM measuring accuracy of 0.5mm. 3. Furthermore all tapers showed low wear volumes indicating that the taper junction had functioned correctly and distributed the load across the length of the truneon. Significance. This work adds to the growing evidence that taper problems in modern hip prostheses are associated with increasing head diameter and smaller taper dimensions

The use of impaction bone grafting during revision arthroplasty of the hip in the presence of cortical defects has a high risk of post-operative fracture. Our laboratory study addressed the effect of extramedullary augmentation and length of femoral stem on the initial stability of the prosthesis and the risk of fracture. Cortical defects in plastic femora were repaired using either surgical mesh without extramedullary augmentation, mesh with a strut graft or mesh with a plate. After bone impaction, standard or long-stem Exeter prostheses were inserted, which were tested by cyclical loading while measuring defect strain and migration of the stem. Compared with standard stems without extramedullary augmentation, defect strains were 31% lower with longer stems, 43% lower with a plate and 50% lower with a strut graft. Combining extramedullary augmentation with a long stem showed little additional benefit (p = 0.67). The type of repair did not affect the initial stability. Our results support the use of impaction bone grafting and extramedullary augmentation of diaphyseal defects after mesh containment

Background. Around 1% of patients who have hip replacement have deep prosthetic joint infection afterwards. Infection is treated with antibiotics and revision surgery. We aimed to characterise the impact of deep joint infection and its treatment, to identify treatment preferences, and to describe surgeons' treatment decisions. Methods. In a qualitative study in the UK we interviewed 19 patients who had infection after hip replacement and 12 orthopaedic surgeons specialising in infection. Face-to-face interviews with patients explored experience of infection, treatment and recovery. Interviews with surgeons explored treatment decisions. With consent, interviews were audio-recorded, transcribed and anonymised. Once imported into QSR NVivo software, data were analysed using constant comparison. Results. Patients with deep joint infection described mobility loss, pain, loss of valued activities, changes to home environments/moving into care, negative impact on personal relationships and financial strain. Physical and psychological trauma was associated with revision surgery and antibiotic treatment. Patients had strong preferences for treatment options, emphasising impact of surgery, side effects of antibiotics and duration of treatment as key considerations. Although eradication of infection was important, patients felt that reducing impact of treatment was high priority and identified a need for more support. Surgeons' treatment decisions focused on patient characteristics and nature of infection to prioritise eradication of infection. During patients' recovery surgeons' were concerned about possible return of infection and patients' mobility and function. Conclusion. Infection after joint replacement causes physical and psychological trauma. Balancing patients' preferences for reducing impact of treatment with surgeons' emphasis on eradication of infection should be an important consideration in care. There is also need to develop new interventions to support patients with infection. Level of evidence. Level 3 – Qualitative Research. Funding statement. This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1210-12005). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Ethics. This study has been given a favourable opinion for conduct in the NHS by the National Research Ethics Service Committee South West – Exeter 14/SW/0072

250 words max Long polished cemented femoral stems, such as the Exeter Hip Revision stem, are one option available to the revision hip arthroplasty surgeon. When proximal bone stock is compromised, distal fixation is often relied upon for stability of the femoral component. In such circumstances, torsional forces can result in debonding and loosening. This study compared the torsional behaviour of a cemented polished and featureless (plain) stem with cemented, polished stems featuring fins or flutes. Nine torsional tests were carried out on each of these three different stem designs. The finned stem construct was significantly stiffer than the fluted stem (mean 24.5 Nm/deg v 17.5 Nm/deg). The plain stem mean stiffness was less than the featured stems (13 Nm/deg), but wide variability lead to no statistically significant difference. The maximum torque of the finned (30.5 Nm) and fluted stems (29 Nm) was significantly higher than the plain stem (10.5 Nm); with no significance to the difference between the finned and fluted stems. Distal stem features may provide a more reliable and greater resistance to torque in polished, cemented revision hip stems. Finned stem features may also increase the stiffness of the construct. Consideration should thus be given to the incorporation of distal stem features in the design of revision hip stems

The aim of this study was to characterise noise associated with ceramic-on-ceramic total hip arthroplasty (THA). A questionnaire was constructed to assess noise associated with THA. 116 patients responded. All had ceramic-on-ceramic hybrid THA at Glasgow Royal Infirmary between 2005 and 2007 using a Trident prosthesis and Exeter stem. Oxford Hip Questionnaires (OHS) were also completed by the patients. 16.4% of respondents reported noise associated with their ceramic hip. The vast majority reported onset at least 1 year after implantation. The most common noise types were ‘clicking’ (47%) or ‘grinding’ (42%), while ‘squeaking’ was least frequently reported (11%). Noise was most commonly brought on by bending and during sit to stand movements. No correlation was identified between the incidence of noise and any patient specific factor or demographic variable. The mean OHS at questionnaire follow-up was 39 and there was no significant difference in OHS when comparing noisy and silent hips (p=0.65). Only 1 patient limited social or recreational activities and overall patients felt the noise had minimal effect on their quality of life. Acetabular component inclination angles were compared on post-operative x-rays. There was no significant difference (p=0.51) in inclination angles of the noisy (47.1°±6.3°, range 30–57°) and silent hips (47.8°±6.1°, range 35–68°). The groups were further analysed for deviation out with the desirable inclination range of 40–45°. Of the noisy hips, a total of 73% were out with this range compared to 63% in the silent hip group. The incidence of noise within this ceramic-on-ceramic THA group did not appear to be related to patient specific factors, patient reported outcome (OHS) or acetabular inclination angles. Subjective appraisal of the noise revealed that ‘squeaking’ was not common but patients tended to report ‘clicking’ and ‘grinding’ more. The precipitation of noise with bending activities reinforces a possible mechanical cause

In recent years the majority of X-ray departments have moved to a digital format of recording and archiving radiographs. These digital images (as with previous ‘films’) have a built in magnification factor (variable with each patient), which, may cause errors in templating for joint replacement surgery. Placing a marker of known size at the same level as the joint in question allows calculation of the magnification. This may help to restore hip offset in total hip replacement. To establish the magnification factor for digital radiographs taken in our unit. To assess the usefulness of marker images in accurate preoperative templating. Preoperative marker radiographs were identified retrospectively. The apparent size of the marker was measured on digital image. This value was used to calculate the magnification of the image. The scaled X-ray was up loaded to a digital templating software programme. This software uses a ‘scaling tool’ to calculate the magnification of the image. The hip joint templating tool was the used to calculate the offset of the proximal femur, this was performed with the calculated magnification and also an assumed magnification of 120%. The recommended offset of Exeter V40 stem was noted for both values. Images were identified for 40 patients with markers. The average magnification was 122% for both PACS and Orthoview with a range 113% – 129% and a standard deviation of 4%. The median value for magnification was 120%. The average change in offset between calculated and estimated magnification was 1.275mm with a maximum change of 3mm. In two cases this difference resulted in a change in the recommended offset (5%). The use of marker radiographs is widely described. In this small series the magnification is the same as previously reported in other studies. The difference in offset between calculated and estimated magnification was relatively small and caused a change in the recommended offset in only two patients. Variation in the use of the templating tool in our software can produce a much greater change in offset. Marker radiographs will only be useful as part of a standardised method of pre-operative templating

Prosthesis migration and acetabular cup wear are useful short term measurement which may predict later implant outcome. However, the significance of the magnitude and pattern of the migration is very much dependent on the specific design studied. This study aimed to characterise patterns of migration by following four cemented femoral stem designs using Radiostereometry (RSA) within a prospective randomised longitudinal trial. 164 patients undergoing cemented femoral hip replacement for osteoarthritis were randomised to receive either an Exeter (Howmedica Stryker), Ultima Tapered Polished Stem (TPS) (Depuy), Ultima Straight Stem (USS) (Johnson and Johnson) or Elite Plus (Depuy) stem. Each subject received the OGEE PE cemented acetabular component (Depuy). RSA examinations were performed at 1 week and 6, 12, 18, 24 and 60 months post surgery. They were analysed using the UMRSA system (RSA Biomedical AB, Umea, Sweden), and our local geometric stem measurement software. 149 patients had RSA measurements available to 2 years, and 96 patients to 5 years. Differences were analysed using mixed linear modelling (SPSS). Median linear proximal cup wear rate reduced to a minimum of 0.02-0.06mm/year in year two. Between 2 and 5 years the wear rate increased, being significantly higher for the Elite. Cup migration was small but continuous. At 2 years it was median 0.3mm proximally, increasing to 0.5 mm at 5 years. Median rotations were less than 0.3 degrees. Proximal migration was positive and increasing at all time points for all stems. For the tapered polished designs, while the overall magnitude was significantly higher, the rate of migration significantly decreased, whereas for the other stem designs it did not. The TPS stem showed a tendency for posterior tilt which was significant compared to the other stems at 5 years. All stems tended to retroversion, with the USS significantly less than the others and the Elite showing and relative increase at 5 years. In summary migration patterns are characterised by the stem design, including where there were only small changes between designs. We are now testing measured migrations as predictors of outcome, and will continue to follow this group of patients to 10 years

Impacted morsellised allografts have been used successfully to address the problem of poor bone stock in revision surgery. However, there are concerns about the transmission of pathogens, the high cost and the shortage of supply of donor bone. Bone-graft extenders, such as tricalcium phosphate (TCP) and hydroxyapatite (HA), have been developed to minimise the use of donor bone. In a human cadaver model we have evaluated the surgical and mechanical feasibility of a TCP/HA bone-graft extender during impaction grafting revision surgery.

A TCP/HA allograft mix increased the risk of producing a fissure in the femur during the impaction procedure, but provided a higher initial mechanical stability when compared with bone graft alone. The implications of the use of this type of graft extender in impaction grafting revision surgery are discussed.

We carried out a cross-sectional study with analysis of the demographic, clinical and laboratory characteristics of patients with metal-on-metal hip resurfacing, ceramic-on-ceramic and metal-on-polyethylene hip replacements. Our aim was to evaluate the relationship between metal-on-metal replacements, the levels of cobalt and chromium ions in whole blood and the absolute numbers of circulating lymphocytes. We recruited 164 patients (101 men and 63 women) with hip replacements, 106 with metal-on-metal hips and 58 with non-metal-on-metal hips, aged < 65 years, with a pre-operative diagnosis of osteoarthritis and no pre-existing immunological disorders.

Laboratory-defined T-cell lymphopenia was present in13 patients (15%) (CD8⁺ lymphopenia) and 11 patients (13%) (CD3⁺ lymphopenia) with unilateral metal-on-metal hips. There were significant differences in the absolute CD8⁺ lymphocyte subset counts for the metal-on-metal groups compared with each control group (p-values ranging between 0.024 and 0.046). Statistical modelling with analysis of covariance using age, gender, type of hip replacement, smoking and circulating metal ion levels, showed that circulating levels of metal ions, especially cobalt, explained the variation in absolute lymphocyte counts for almost all lymphocyte subsets.