After the original development of the Exeter polished stems, much work was done, extending over years, in the Departments of Engineering Science and Chemistry of the University of Exeter, as well as at the Princess Elizabeth Orthopaedic Hospital, on various aspects of acrylic cement and its use in hip arthroplasty, including its mechanical properties12,62,63,64, metabolism and cardiovascular effects65,66,67,68,69, thermal effects70 and ways of improving its use71,72.

The technique of using cement was gradually refined throughout the late seventies and early eighties, based initially on 2 in vitro studies that had been carried out in Exeter64,71. These showed that by a using a combination of the exposure of strong cancellous bone in the femur, thorough pressure washing of the bone surface followed by the subsequent plugging & retrograde filling of the femur with reduced viscosity cement dough and ‘closed cavity’ pressurisation of the femoral canal, a fourfold increase in the shear strength of the cement-bone interface could be regularly produced. The clinical application of such methods was flawed initially by failure to appreciate the potentially damaging effects of bleeding at the cement-bone interface that can occur in clinical practice. This may have contributed to some of the indifferent results with the matt-surfaced stems in the early eighties.   These effects were clarified in 2 further studies73,73, and taken in conjunction with an extensive laboratory simulation study5 formed the basis for the femoral cementing technique that has been in use in Exeter since approximately 1984. This concentrates on the retrograde insertion of reduced viscosity cement dough into a thoroughly clean and distally plugged medullary canal, followed by prolonged pressurisation of the cavity using a gun and proximal seal, the delayed insertion of a pre-warmed74 stem and the subsequent pressurisation of the proximal end of the canal using a seal around the stem that is retained until polymerisation75. No attempts have ever been made in Exeter to reduce porosities in the cement because the evidence for doing so was not considered to be valid76.