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Chris Moran - Queen's Medical Centre, Nottingham - Nottingham, UKAndrew Manktelow - Queen's Medical Centre, Nottingham - Nottingham, UK*Email: jonphillips99@hotmail.comThe clinical results of the cemented Exeter stem in primary hip surgery have been excellent.The Exeter ‘philosophy’ has also been extended into the treatment of displaced intracapsular hipfractures with ‘cemented bipolars’ and the Exeter Trauma Stem (Howmedica).We have identified an increase in the number of periprosthetic fractures that we see around theExeter stem. We have also identified a particular group of patients with comminuted fracturesaround ‘well fixed’ Exeter stems after primary hip surgery that present a particular difficultclinical problem.Prior to fracture, the stems are not loose, the cement mantle remains sound and bone qualitysurrounding the reconstruction is good, i.e. classifying it as a Vancouver B1. However thecomminuted nature of the fracture makes reduction and fixation with traditional methodsdifficult. Therefore in these particular circumstances it is often better to manage these as B2 oreven B3 fractures, with distal bypass and uncemented reconstruction.Over an eleven-year period since 1999, 185 patients have been admitted to NottinghamUniversity Hospitals with a periprosthetic femoral fracture around a hip replacement. Thesepatients were identified from a prospective database of all trauma patients admitted to theinstitution. Of these patients we have identified a cohort of 21 patients (11%) with aperiprosthetic fracture around an Exeter polished stem. Hospital notes were independentlyreviewed and data retrieved. Outcome data was collected with end points of fracture union, rerevisionsurgery and death. Data was also collected on immediate and long term post-operativecomplications.The mean age was 76 years at time of fracture, and 52% were male. The mean durationbetween primary index surgery and fracture was 18 months (median 11 months).15 patients were classified as Vancouver B1, and six as B2 fractures. Of the B1 fractures, 14underwent fixation and one was treated non-operatively. Of the B2 fractures, four were revised,one was revised and fixed using a plate, and one was fixed using a double-plating technique.Prior to fracture, none of the implants were deemed loose although one patient was underreview of a stress fracture which subsequently displaced.One patient died prior to fracture union. All the other patients subsequently went onto unite at amean of 4 months. There were no deep infections, non- or malunions. No patient underwentfurther surgery. Dislocation occurred in one patient and a superficial wound infection occurredin one patient which responded to antibiotic treatment. Three other patients have subsequentlydied at seven, twelve and fifty-three months post fracture due to unrelated causes.In our series of patients, in addition to the more standard fracture patterns, we have identified avery much more comminuted fracture. Indeed, we have described the appearance as if thetapered stem behaves like an axe, splitting the proximal femur as a consequence of a directaxial load. As a consequence of the injury, the cement mantle itself is severely disrupted. Thereis significant comminution and soft tissue stripping, calling into question the viability of theresidual fragments. Treatment of this type of fracture using a combination of plates, screws andcables is unlikely to provide a sufficiently sound reconstruction. In our experience we believethese fractures around previously ‘well fixed’ Exeter stems should be treated as B2/B3 injuries.file:///E|/ISTA2010-Abstracts.htm[12/7/2011 3:15:47 PM]