Exeter Trauma Stem Research Articles

Long-term implant survival following hemiarthroplasty for fractured neck of femur.

Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty. Patients recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) between 1 September 1999 and 31 December 2020 who underwent hemiarthroplasty for the treatment of a hip fracture with the following implants were included: a cemented monoblock Exeter Trauma Stem (ETS), cemented Exeter V40 with a bipolar head, a monoblock Thompsons prosthesis (Cobalt/Chromium or Titanium), and an Exeter V40 with a Unitrax head. Overall and age-defined cumulative revision rates were compared over the ten years following surgery. A total of 41,949 hemiarthroplasties were included. Exeter V40 with a Unitrax head was the most commonly used (n = 20,707, 49.4%). The overall rate of revision was small. A total of 28,201 patients (67.2%) were aged > 80 years. There were no significant differences in revision rates across all designs of hemiarthroplasty in patients of this age at any time. The revision rates for all designs were < 3.5%, three years postoperatively. At subsequent times the ETS and Exeter V40 with a bipolar head performed well in all age groups. The unadjusted ten-year mortality rate for the whole cohort was 82.2%. There was no difference in implant survival between all the designs of hemiarthroplasty in the first three years following surgery, supporting the selection of a cost-effective design of hemiarthroplasty for most patients with an intracapsular fracture of the hip, as determined by local availability and costs. Beyond this, the ETS and Exeter bipolar designs performed well in all age groups.

Implant and patient survival rates using Exeter Trauma Stem hemiarthroplasty in fracture neck of femur patients: The largest study to date

IntroductionExeter Trauma Stems (ETS) femoral hemiarthroplasties are based on Exeter THR stems with a few design changes. Little has been published on ETS survival rates to justify their high cost compared to other cheaper implants. This is the largest prospective study to assess ETS implant failure-free survival rates in fracture neck of femur patients (NOF). This non-developing-centre study examined whether these design differences have altered implant survival (compared with Exeter THR's published survival data). MethodsData were prospectively collected by independent audit officers. Dislocation, periprosthetic fracture, re-admission with severe hip pain, deep infection and revision surgery were considered events of interest in implant failure-free survival. ResultsThis study assessed 1,123 ETS stems (36 patients received bilateral ETS) in NOF patients. The mean patient age at the time of operation was 83 years (range; 49 – 102 years). The mean observation period was 2.5 years (range; 0 days - 8 years). Only 29 implants failed. All failure events were reported within the first year. Stem failure-free survival was 97.2% at eight years (CI 95.9% - 98%). Dislocation occurred in 10 patients (1%), periprosthetic femoral fracture in 4 (0.4%), and deep infection in 11 patients (1.2%). Patient survival rates were 75% and 48% at one and five years respectively. ConclusionETS has high implant failure-free survival rates when used in hip fractures. ETS design changes have not altered ETS survival when used in hip fractures compared with the published literature of Exeter THR stem when used as a treatment for OA. Exeter Trauma Stems in NOF patients might last these elderly patients their entire short lifetime.

Hip Hemiarthroplasty: The Misnomer of a Narrow Femoral Canal and the Cost Implications.

ObjectiveHemiarthroplasty has been identified as the treatment of choice for displaced intracapsular femoral neck fractures. A modular prosthesis is sometimes preferred for its sizing options in narrow femoral canals, despite its higher cost and no advantage in clinical outcomes. Thus, in this study, we investigated the factors affecting surgeons’ choice of prosthesis, hypothesizing that modular hemiarthroplasty is overused for narrow femoral canals compared to monoblock hip hemiarthroplasty.MethodsA retrospective study of a regional level 1 trauma center was conducted. Patients who had sustained femoral neck fractures from March 2013 to December 2016 were included in this study. Inclusion criterion was modular hemiarthroplasty for a narrow femoral canal. A matched group of patients who underwent monobloc hemiarthroplasty (MH) was created through randomization. The main outcome measurements were sex, age, Dorr classification, and femoral head size. We measured the protrusion of the greater trochanter beyond the level of the lateral femoral cortex postoperatively. Modular hemiarthroplasty patients were templated on radiographs using TraumaCad for Stryker Exeter Trauma Stem (ETS®).ResultsIn total, 533 hemiarthroplasty procedures were performed, of which 27 were modular for a narrow femoral canal. The ratio of modular to monobloc was 1:18. Average head size was 46.7 mm ± 3.6 mm for monobloc and 44.07 ± 1.5 for modular (P= 0.001). There were four malaligned stems in the monobloc group versus 14 in the modular group (P= 0.008). Unsatisfactory lateralization was noted in 18 patients (7 mm ± 2.9 mm) in the modular group compared with 8 (4.7 mm ± 3.9 mm) in the monobloc group (P= 0.029). Dorr classification was A or B in 24 patients in the modular group and 18 in the monobloc group (P = 0.006). Templating revealed that modular was not required in 25 patients.ConclusionsAs per our findings, it was determined that patients with a narrow femoral canal intraoperatively should not receive modular hemiarthroplasty. This is especially true for female patients with small femoral head and narrow femoral canal dimensions (Dorr A and B). They would require extensive careful planning. Surgical techniques should be explored through education intraoperatively to achieve lateralization during femoral stem preparation. This may avoid prolonged anesthetic time and achieve potential cost savings.

The Exeter Trauma Stem: A radiographic follow-up at minimum of five years post implantation

IntroductionThe Exeter Trauma Stem (ETS) has been recommended by National Institute of Clinical Excellence (NICE) guidelines in the United Kingdom as a proven, cemented stem. A single laboratory study in the literature has raised possible concerns about the polished finish of the ETS and subsequent potential for accelerated loosening although there is little clinical evidence to support or refute this. MethodsThe aim of this study was to assess clinical outcomes of the ETS at a minimum of five years post implantation. Primary outcomes were radiological loosening at a minimum of five years along with survivorship of the implant. Patient demographics were prospectively collected and followed up. Results218 ETS’s (in 214 patients) were implanted from June 2002 until August 2008 in a single centre by a wide variety of surgeons of differing grades. Of these, 16 underwent revision surgery for fracture (2), dislocation (3), infection (1) and acetabular erosion (10) but there were no revisions for aseptic loosening of the implant. There were 64.0% (137/214) patients that had died by the time of this study. Of the remaining patients, 90 had radiographs of their hips at a minimum of 5 years with 36 of these at a minimum of 7 years post implantation. None of these had evidence of loosening. ConclusionThe ETS is a robust and suitable stem for implantation in patients with hip fractures. There are no clinical suspicions or increased rates of loosening with the ETS in our study. The concerns about surface finish are not borne out in our clinical study which shows no evidence of loosening at a minimum of five years post operation. It confers many advantages including ease of revision and it should continue to be used as per NICE guidelines.

Medium to long term follow up of a consecutive series of 604 Exeter Trauma Stem Hemiarthroplasties (ETS) for the treatment of displaced intracapsular femoral neck fractures

The aim of this study was to evaluate the medium to long term follow up results for the Exeter Trauma Stem (ETS) in the treatment of displaced femoral neck fractures. We retrospectively evaluated 604 consecutive cemented ETS hemiarthroplasties performed at our institution between 2007 and 2012. The range of follow up was 2–7 years with a mean follow-up of 4.1 years for the surviving patients. The mean age of the patient population was 84 years (range 46–106) with 81.3% female patients. 382 patients (63.2%) died within the follow up period. Postoperative superficial soft tissue infection occurred in 11 patients and deep prosthetic infection in 5 patients. Dislocation occurred in 11 patients and periprosthetic fracture occurred in 7 patients. 11 patients underwent Girdlestone excision arthroplasty and 6 patients were revised to total hip replacement. This paper represents the largest consecutive series for this implant, with the longest follow up currently available. The results confirm that the prosthesis is an excellent implant for these patients with a low risk of needing revision surgery.

Historical Implant or Current Best Standard? Minimum Five Year Follow-Up Outcomes of Cemented Thompson Hemiarthroplasties

UK NICE guidelines recommend abandoning the Thompson hemiarthroplasty (TH) in favour of a ‘proven prosthesis’ such as the Exeter Trauma Stem. The aim of this study was to assess the hip fracture treatment with the TH. Between 2002 and 2006, 430 cemented THs were performed (minimum 5year follow-up). Death rates at 1year and 5years were 26.6% and 67.4% with low complication (Dislocation 1.4%) and revision rate (1.2%). The TH remains a reliable and proven implant in appropriate patients (over the age of 80, with low activity levels, low ambulatory status and who maybe cognitively impaired), due to low complication and revision rates. Modern implants may provide better function or longevity, but there is little evidence to support abandoning the TH.

Reduced Leg Lengthening found with a Modular Hip Hemiarthroplasty Stem versus the Monoblock Equivalent

The frequency of hip fractures are increasing in the globally. Cemented implants offer less pain and improved mobility post operatively. To date there has been no comparison between The Exeter Trauma Stem (ETS), which is a monoblock single size stem versus the Joint Replacement Instrumentation (JRI), a modular cemented hip used in the treatment of intracapsular fracture neck of femur fractures. It was postulated that the monoblock single size stem would be more difficult to insert in smaller femoral canals, and as such would have a greater tendency to lengthen the leg and greater incidence of calcar fractures. Over a 2 year period we have reviewed, the operative complications and radiological outcomes of the JRI hip hemiarthroplasty stem with a matched group of ETS implants. The study highlights the one-size-fits-all ETS system is more likely to be placed longer than a modular JRI system (p=0.01). There was no statistical difference in calcar fractures between the two prostheses. There were 40/99 JRI implants (40%) patients which required a smaller prosthesis than the ETS, these patients may have been over lengthened if the ETS was used. Careful radiographic pre-operative evaluation is required in order to avoid over lengthening the ETS prosthesis in patients with a narrow canal. A modular prosthetic design offers a valuable alternative to such a scenario.

Incidence of periprosthetic fractures after hip hemiarthroplasty: Are uncemented prostheses unsafe?

Displaced intracapsular fractures of the neck of femur are routinely treated in the elderly with either cemented or uncemented hemiarthroplasty. Recent evidence suggests a superior outcome with the use of cement, but uncemented prostheses are still employed for those with multiple co-morbidities or particular frailty. In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) recommendations are used to identify which patients should receive a cemented prosthesis. These are simply based upon the presence of cardiorespiratory disease, particularly in the frail elderly patient.Between January 2007 and June 2010, a total of 1397 patients with neck-of-femur fractures presented to our unit. Retrospective analysis was performed with particular attention given to the rate of postoperative periprosthetic fracture. As many as 546 fractures were treated with hemiarthroplasty, of which 183 were treated with a cemented Exeter Trauma Stem (ETS) and 363 were treated with an uncemented Austin-Moore prosthesis (AMP). At the time of our retrospective analysis, we found that 15 (4%) patients treated with an uncemented prosthesis went on to sustain a periprosthetic fracture. There were no periprosthetic fractures in the cemented group (p=0.004). Data analysis by case-note review of those patients sustaining a periprosthetic fracture was then performed. Seven (50%) suffered from confusion secondary to dementia, six (43%) had a history of significant cardiac disease (recent myocardial infarction (MI) or cardiac failure) and two (14%) had known renal impairment. The mean time to fracture after uncemented hemiarthroplasty was 2 years. The majority (80%) were fractures which required further surgery. Revision surgery in these patients was associated with an overall complication rate of 42% (mainly deep infection and haemorrhage requiring transfusion). Two of the patients had a fracture that could be treated conservatively.It is concluded that, in conjunction with the treating senior anaesthetist, cemented implants should be considered in all patients, especially those who are deemed to be frail and with multiple co-morbidities. A periprosthetic fracture rate of 14% at a mean of 2 years after uncemented hemiarthroplasty represents a potentially unacceptable risk for such a frail population. In particular, we feel that the AMP should not be used for treating displaced intracapsular neck-of-femur fractures.

Response to: Petheram TG, Bone M, Joyce TJ, et al. Surface finish of the Exeter Trauma Stem: a cause for concern? Bone Joint J 2013;95-B:173–6.

Dear Sir, The Exeter Trauma Stem (ETS) was introduced into clinical practice in 2002 and was conceived as a low-cost treatment option for elderly, low-demand patients with a displaced intracapsular fracture of the neck of the femur. The intention was to create a hemiarthroplasty with similar

Surface finish of the Exeter Trauma Stem

Recent guidance recommends the use of a well-proven cemented femoral stem for hemiarthroplasty in the management of fractures of the femoral neck, and the Exeter Trauma Stem (ETS) has been suggested as an example of such an implant. The design of this stem was based on the well-proven Exeter Total Hip Replacement stem (ETHRS). This study assessed the surface finish of the ETS in comparison with the ETHRS. Two ETSs and two ETHRSs were examined using a profilometer with a precision of 1 nm and compared with an explanted Exeter Matt stem. The mean roughness average (RA) of the ETSs was approximately ten times higher than that of the ETHRSs (0.235 μm (0.095 to 0.452) versus 0.025 μm (0.011 to 0.059); p < 0.001). The historical Exeter Matt stem roughness measured a mean RA of 0.973 μm (0.658 to 1.159). The change of the polished Exeter stem to a matt surface finish in 1976 resulted in a high stem failure rate. We do not yet know whether the surface differences between ETS and ETHRS will be clinically significant. We propose the inclusion of hemiarthroplasty stems in national joint registries.

Comparison of the Exeter Trauma Stem and the Thompson Hemiarthroplasty for Intracapsular Hip Fractures

A planned change in the prosthesis used for hip hemiarthroplasty in one orthopaedic trauma unit from the Thompson prosthesis to the Exeter Trauma Stem (ETS) was studied. We completed a prospective continuous audit study comparing outcomes for patients undergoing the procedure before (766 patients) and after (388 patients) the change of practice. Outcomes measured included surgical complications (including infection or dislocation) and a postoperative radiographic review. There was no difference in the incidence of surgical complications between the groups, and no difference in ratings given to postoperative radiographs between both groups. In theory, the ETS may be easier to revise, should this be required in future, but in other respects the devices are comparable.

Hip fracture management and NICE guidelines

Hip fractures are an economic burden on the NHS. In view of the variety of practice nationwide, the National Institute for Health and Clinical Excellence released hip fracture guidelines in June 2011. After the draft in November 2010, we audited our own practice to examine what changes need to take place to reach compliance with the guidelines. 109 patients were prospectively identified to be included in the study with no exclusions. Demographic, operative and surgical data were collected and compared with the proposed guidelines. There were 8 undisplaced intracapsular fractures, 48 displaced intracapsular fractures, 47 simple extracapsular fractures and 6 complex extracapsular fractures. 17 patients were suitable for THR, but only 3 received this procedure. 43 hemiarthroplasties were performed, of which 93% were of a proven stem design. 53 patients sustained extracapsular fractures of which 90% received the approved implant fixation. 5 patients received cannulated hip screws and 4 patients were treated conservatively. Areas for rationalisation of equipment can provide economic savings for the trust. In particular, older-fashioned Thompson and Austin-Moore hemiarthroplasties may be completely replaced with the Stryker Exeter trauma stem. The institution needs to ensure that there is an available arthroplasty surgeon and an available trauma list every day. Rationalisation of trauma equipment and consignment will provide savings for the trust.

Monoblock hemiarthroplasties for femoral neck fractures – A part of orthopaedic history? Analysis of national registration of hemiarthroplasties 2005–2009

This study from the Swedish Hip Arthroplasty Register (SHAR) compares cemented (Thompson®, Exeter Trauma Stem (ETS)®) and uncemented (Austin-Moore®) monoblock hemiarthroplasties (n=1116 and 616, respectively) with modular ones (n=18,659).Austin-Moore® prostheses lead to more re-operations (6.7%) compared to modular implants (3.5%) and Thompson®/ETS® (2.4%).A Cox regression analysis, adjusting for other risk factors, shows twice the risk of re-operation for Austin-Moore® implants (CI 1.5–2.8), in particular, due to periprosthetic fracture (5.4; CI 3.2–9.1) and dislocation (1.9; CI 1.3–3.0). The Thompson®/ETS® implants do not influence the overall risk of re-operation (0.7; CI 0.5–1.2) compared to modular implants and decrease the risk of re-operation due to infection (0.2;CI 0.04–0.7). An increased risk of re-operation is also seen in men, age groups 75–85 years and <75 years and after secondary fracture surgery.Both Swedish and Australian orthopaedic surgeons have decreased their use of Austin-Moore® implants after reports from their national arthroplasty registers identifying inferior outcome for this implant. Due to the increased risk of re-operations, it should not be used in modern orthopaedic care. Cemented Thompson® or ETS® implants could still be suitable for the oldest, low-activity patients. To finally decide if there is a place for them, patient-reported outcome must be analysed as well.

Cemented Thompson hemiarthroplasty versus cemented Exeter Trauma Stem (ETS) hemiarthroplasty for intracapsular hip fractures: A randomised trial of 200 patients

Numerous different designs of hemiarthroplasty are available but few have been compared within the context of a randomised controlled trial. Two-hundred patients presenting with a displaced intracapsular fracture of the hip were randomised to receive either a cemented Thompson hemiarthroplasty or a cemented smooth tapered stem hemiarthroplasty (Exeter Trauma Stem). All operations were undertaken or directly supervised by one surgeon using the same operative approach. Patients were followed up for 1 year from injury by a research nurse blinded to the treatment used. The smooth tapered stem was felt to present less operative difficulties compared to the Thompson prosthesis. There were no other statistically significant differences in outcomes between the two prostheses.

Exeter trauma stem—An early experience in a DGH

Exeter trauma stem—An early experience in a DGH

6 month retrospective study assessing the performance, surgeon satisfaction and complications of the newly introduced Exeter Trauma Stem hip hemiarthroplasty compared to the previously used logic stem

6 month retrospective study assessing the performance, surgeon satisfaction and complications of the newly introduced Exeter Trauma Stem hip hemiarthroplasty compared to the previously used logic stem

High rate of conversion of Exeter Trauma Stem Hemiarthroplasty to bi-polar prosthesis: Should we template X-rays preoperativelly?

High rate of conversion of Exeter Trauma Stem Hemiarthroplasty to bi-polar prosthesis: Should we template X-rays preoperativelly?

The direct lateral approach to the hip.

A direct lateral approach to the hip is described which allows adequate access for orientation of the implant, for the insertion ofthe cement and for the correction ofdiscrepancy in leg length. An anatomical observation was made that the gluteus medius muscle is inserted into the greater trochanter by a tendon and that the axis of the shaft of the femur lies anterior to the main bulk of the muscle which was left