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