Fracture of an Exeter ‘Cement in Cement’ Revision Stem: A Case Report

O’Neill, Gavin Kane; Maheshwari, Ramesh; Willis, Courtney; Meek, Dominic; Patil, Sanjeev

doi:10.5301/hip.2011.8652

Cited by 22 publications

(24 citation statements)

References 2 publications

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“…Biomechanical analysis was not performed however as part of this paper. O’Neill et al once again described a similar stem fracture in July 2011 11. This case report describes a patient who suffered a similar stem fracture in an Exeter that was implanted as part of a prior revision.…”

Section: Discussionmentioning

confidence: 83%

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History, treatment and analysis of a rare form of Exeter stem fracture

et al. 2019

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The Exeter stem by Stryker has become one of the most successful and widely used stems in modern cemented hip arthroplasty. We present a case of a rare stem fracture which was treated by ‘cement-in-cement’ revision arthroplasty technique. The patient, an 87-year-old man, presented with left hip pain and an inability to weight bear following a cracking sensation when he was standing to dress himself. The patient denied history of fall or trauma. On examination he was noted to have a shortened externally rotated left lower limb without neurovascular compromise. On pelvic radiograph he was noted to have an incomplete stem fracture of his left-sided total hip replacement. He was treated with a cement-in-cement revision. Postoperatively the stem was sent for analysis in the London Implant Retrieval Centre. This is an example of a rare form of stem fatigue failure treated with a well-described technique in revision arthroplasty.

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Section: Discussionmentioning

confidence: 83%

“…There are reportedly a vast number of indications for ‘cement-in-cement’revision. The above studies each describe cement-in-cement revision techniques in the treatment of basal stem fracture of the Exeter introducer hole 11–14…”

Section: Discussionmentioning

confidence: 99%

History, treatment and analysis of a rare form of Exeter stem fracture

et al. 2019

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“…Several other risk factors for stem breakage have previously been identified including laser etching of the stem and other potential mechanical stress risers. 14,[42][43][44][45] A further commonly cited risk factor is component varus positioning. 15,39,46 While the majority of cemented stem breakages reported in the literature are in the mid-third region, there are some reports of cemented stems breaking through the neck.…”

Section: Discussionmentioning

confidence: 99%

Risk factors for femoral stem breakage: an analysis of the AOANJRR results

et al. 2019

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Introduction: Breakage of the femoral stem component of a total hip replacement is now uncommon but continues to be seen with certain stem designs and in certain patient groups. Data previously published on this topic has been limited, either gathered from a single surgeon or centre, or included only a single stem design. Methods: We reviewed the data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), identified and analysed 143 stem breakages over a period of 16 years, covering 44 different stem designs. Results: Our data confirms previously published findings that risk factors for stem breakage include patient age at implantation of under 70, male gender, as well as the use of exchangeable necks. We found no association with initial diagnosis, or type of acetabular component implanted. We did however also find, excluding exchangeable neck designs, that after 4.5 years a cemented stem had a significantly higher risk of breakage then a cementless stem. Discussion: To our knowledge this is the 1st paper to suggest cemented fixation as a specific risk factor for stem breakage. The analysis of rare complications such as stem breakage is only possible through large data collection systems such as the AOANJRR. Whilst there have been recent advances in materials and manufacturing techniques, we recommend that surgeons are aware of all the specific risks when considering implant choices for individual patients.

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“…There are also some clinical concerns about the risk of stem fracture if a smaller stem is required. 15 An in-cement revision has all the benefits of a cement-incement revision with the added incentive of using the same size primary stem. In regions with economic pressures, provided the original stem is in good condition, it could also potentially be reused, saving the cost of a new stem.…”

Section: Discussionmentioning

confidence: 99%

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

McDougall

Calligeros

et al. 2016

Journal of Orthopaedics

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A valuable technique for femoral stem revision in total hip replacement: The in-cement revision -A case series and technical note IntroductionRevision of a cemented femoral stem can be a challenging procedure. Removing the cement mantle requires time and patience with a risk of further bone damage and possible fracture.1-4 Retention of the old cement mantle and insertion of a smaller or shorter stem -the cement-in-cement revisiondescribed for taper stems -provides a good alternative if the cement mantle is stable, but is limited if a smaller size or offset stem is already in situ. We present a newly described technique, the ''In-cement'' revision -the introduction of a stem, the same size as the original implant, into the previous cement mantle, without additional cement or downsizing. This has not been previously described or investigated in the literature. We present the technique and a series of 23 cases. In-cement revision requires an intact and stable cement mantle in the correct version. The benefits include improved view of the acetabulum, time efficiency, the ability to use the same size stem and utilisation of the previous distal centralised spacer plug to facilitate subsidence. TechniqueAfter either general or spinal anaesthetic, the patient is positioned laterally. An incision is made through the previous scar and the hip is exposed through a posterior approach. After appropriate dissection and debridement, the hip is dislocated, the head tapped off and the cemented, polished, tapered stem is removed (Fig. 1).There are three primary keys in the technique:1. Inspection of the cement mantle for stability and version (Fig. 2).Inspect the cement mantle for cracks and coverage. Forceps or a pituitary rongeur are used to attempt to mobilise the cement and therefore determine if it is stable. Version is assessed and is deemed either appropriate or not appropriate. If the version of the previous stem is not appropriate or the cement mantle is not stable, an in-cement revision should not be pursued. 2. Protection of the cement mantle (Fig. 3).Place a moist swab in the canal to prevent debris from the acetabular revision dropping into the cement mantle.The acetabulum is then exposed and revised as appropriate. 3. Reinsertion of the same size stem without a centraliser (Fig. 4).No centraliser is used to facilitate subsidence. Tap in the stem until it re-engages with the taper. Double check the length of the 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 rerevision for...

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Fracture of an Exeter ‘Cement in Cement’ Revision Stem: A Case Report

Cited by 22 publications

References 2 publications

History, treatment and analysis of a rare form of Exeter stem fracture

History, treatment and analysis of a rare form of Exeter stem fracture

Risk factors for femoral stem breakage: an analysis of the AOANJRR results

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

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