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Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation.

ABSTRACT: Varus malalignment in total hip arthroplasty has been associated with poor long-term outcomes and complications including abnormal load distribution, endosteal osteolysis, frank loosening, and periprosthetic fractures. Postoperative radiographic assessment was performed on 224 patients from our case series who underwent cemented Exeter total hip arthroplasty using the direct lateral approach alone. No patient had a true varus-aligned stem (ie, ?-5° on the coronal assessment). We describe our surgical technique, with 4 easily reproducible technical tips to achieve positional consistency of the femoral stem: commencing stem insertion from the piriform fossa entry point, using a femoral stem distal centralizer, aiming the tip of the component to the center of the patella, and placing the thumb between the calcar and inferior neck of the femoral component to prevent the stem from tipping into varus.

SUBMITTER: Srinivasan S

PROVIDER: S-EPMC7475171 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

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Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation.

Srinivasan Sriram S Shah Rohi R Rayan Faizal F Ensor David D Sambhwani Sharan S Menon Dipen K DK

Arthroplasty today 20200830 4

Varus malalignment in total hip arthroplasty has been associated with poor long-term outcomes and complications including abnormal load distribution, endosteal osteolysis, frank loosening, and periprosthetic fractures. Postoperative radiographic assessment was performed on 224 patients from our case series who underwent cemented Exeter total hip arthroplasty using the direct lateral approach alone. No patient had a true varus-aligned stem (ie, ≤-5° on the coronal assessment). We describe our sur ...[more]

PMID: 32923564

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Project description:AimsThe Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.MethodsIn this case-control study, 25 patients (22 female) at mean age of 78 years (70 to 89) received cemented Exeter short stem (case group). Cases were selected based on Dorr type A femora and matched first by Dorr type A and then age to a control cohort of 21 patients (11 female) at mean age of 74 years (70 to 89) who received with cemented Exeter standard stems (control group). Preoperatively, all patients had primary hip osteoarthritis and no osteoporosis as confirmed by dual X-ray absorptiometry scanning. Patients were followed with radiostereometry for evaluation of stem migration (primary endpoint), evaluation of cement quality, and Oxford Hip Score. Measurements were taken preoperatively, and at three, 12, and 24 months and a minimum five-year follow-up.ResultsAt three months, subsidence of the short stem -0.87 mm (95% confidence interval (CI) -1.07 to -0.67) was lower compared to the standard stem -1.59 mm (95% CI -1.82 to -1.36; p < 0.001). Both stems continued a similar pattern of subsidence until five-year follow-up. At five-year follow-up, the short stem had subsided mean -1.67 mm (95% CI -1.98 to -1.36) compared to mean -2.67 mm (95% CI -3.03 to -2.32) for the standard stem (p < 0.001). Subsidence was not influenced by preoperative bone quality (osteopenia vs normal) or cement mantle thickness.ConclusionThe standard Exeter stem had more early subsidence compared with the short Exeter stem in patients with Dorr type A femora, but thereafter a similar migration pattern of subsidence until minimum five years follow-up. Both the standard and the short Exeter stems subside. The standard stem subsides more compared to the short stem in Dorr type A femurs. Subsidence of the Exeter stems was not affected by cement mantle thickness.

Project description:BackgroundThe standard Exeter (Stryker) cemented stem is 150 mm long with standard offsets ranging from 37.5 mm to 56 mm. Exeter short stems of 125 mm are also available in the offsets of 37.5 mm, 44 mm, and 50 mm. In addition, smaller (125 mm or shorter) Exeter cemented stems with offsets of 35.5 mm or less are available. The aim of this study was to examine the New Zealand Joint Registry (NZJR) comparing medium-term survival rates and functional outcomes of standard-length stems with Exeter short stems of various offsets in patients undergoing primary total hip replacement.MethodsUsing the NZJR, we compared the results of 3 separate groups of patients with Exeter stems. Patients with standard 150 mm length Exeter stems (Standard) were compared with patients with Exeter 125 mm stems with regular 37.5 mm, 44 mm, and 50 mm offsets (Short 37+) and Exeter 125 mm stems with offsets of 35.5 mm and below (Short 37-). Demographic data, preoperative diagnosis, patient-reported outcome measures, and reasons for revision were compared between groups. Kaplan-Meier survival analysis and Cox multivariate regression analysis were used to examine implant survival and the influence of stem group on revision rates adjusting for gender, age, diagnosis, and surgical approach.ResultsThere were 43,427 Exeter cemented stems in the NZJR between January 1, 1999 and 31, May 2018; 41,629 Standard, 657 Short 37+, and 1501 Short 37-. In all 3 groups, the posterior surgical approach was preferred (Standard, 76.1%; Short 37+, 94.6%; Short 37-, 76.6%; P < .001). In the Short 37- group, 94.1% were female, while in the other 2 groups, there was an equal gender ratio (P < .001). The Short 37- group was also significantly younger than the other 2 groups with 41.6% younger than 65 years compared with Short 37+ (37.2%) and Standard groups (36.9%) (P < .01). There was no difference in American Society of Anesthesiologists grade between groups. Body mass index (BMI) was significantly higher in both the Short 37- and Short 37 + groups compared with the Standard group (Standard BMI, 28.71; SD 5.72; Short 37+ BMI, 29.69; SD, 6.67; Short 37- BMI, 29.09; SD 7.07; P < .001). The all-cause revision rate for standard stems was 0.55/100 component years (cy) (95% CI: 0.52 to 0.58). The Short 37- group had a higher rate of revision compared with the Standard group (hazard ratio 1.6; 95% CI: 1.3 to 1.98; P < .001), while the Short 37+ group had a hazard ratio of 0.84 (95% CI: 0.38 to 1.88; P = .674) compared with the Standard group. Cox regression analysis controlling for age, gender, diagnosis of OA, and surgical approach did not affect these findings. However, no clinically meaningful difference between Oxford hip scores was observed.ConclusionsThere was a significant difference in revision rates for aseptic loosening with standard-length Exeter stems having a lower revision rate than short Exeter stems with offsets 35.5 mm or less. The Short 37+ groups, despite comprising relatively small numbers, performed similarly to the Standard stem group.

Dataset Information

Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation.

Publications

Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation.

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