Operative technique.
In addition to the Short femoral stem, a cannulated cement reamer has been developed to allow the safe reaming of the distal cement mantle to ensure that the stem with a wingless centraliser will fit into the existing mantle. Use of the reamer also ensures cleaning and roughening of the distal mantle prior to insertion of the new stem. The cavity should be clean and dry prior to re-cementing. Early (3 minutes with Simplex) insertion of the new cement should be performed. A revision cement gun nozzle should be used, followed by proximal pressurization until stem insertion. This operative guide should be read in conjunction with the standard Exeter V40 operative technique.

1.Stem removal.
Proximal cement above the shoulder of the prosthesis must be removed prior to attempts at stem removal, using a burr or chisel (Figs 1 & 2). A stout instrument, such as a Tommy bar or Bristow’s, should be placed under the neck of the prosthesis to prevent the tendency to rotate as it is being knocked out. Failure to do so risks creating high torsional stresses and a spiral fracture of the femur.

2.Distal reaming.
If appropriate, the cannulated distal reamer is inserted into the cement mantle and the distal cement mantle is reamed until the mark on the drill is level with the tip of the greater trochanter (Figs 3, 4 & 5). This ensures that the Short Femoral Stem, with a wingless distal centraliser in place, can be inserted. This depth may need to be adjusted if more distal insertion of the stem is required. Irrigate whilst reaming with Hartmans or Saline (Figs 5 & 6).

3.Trial insertion.
A trial stem can now be used to ensure that the correct depth of insertion and stem version can be achieved. Remove proximal cement with a burr or reamers until the desired position can be achieved. A trail reduction can now be performed to confirm stability and leg length (Fig 6). Mark the proximal femur in relation to the marks on the femoral stem, or use the leg length gauge, to facilitate subsequent correct placement of the stem.

4.Canal preparation.
Roughen the proximal cement with a burr, rasp or reamers and then wash and thoroughly dry the canal. Insert a narrow catheter, attached to suction, to the tip of the cavity, followed by a dry gauze pack, and leave in place until just before cement insertion.

4.Retrograde cement insertion.
Remove the gauze and catheter and using a narrow revision nozzle, insert cement with a cement gun. Introduce the cement early (at 3 minutes with Simplex). Use a proximal half moon seal and pressurise the cement continuously until ? stem cement insertion (5 to 6 minutes for Simplex at 21 0C) (Figs 7 & 8).

5.Insert the stem.
Insert the stem. Use a wingless centraliser unless the distal cavity is greater than 10mm in diameter, in which case a winged centraliser can be used. Maintain proximal pressure, first with a thumb and then with a horse collar seal until the cement has polymerised (Figs 9 & 10). Ensure a small amount of cement is placed over the lateral shoulder of the stem, to prevent it from being pulled out of the mantle as during the manipulative reduction of a post-operative dislocation..

6.Reduction
A further trial reduction can now be performed prior to selecting the appropriate femoral head and engaging it on the morse taper.

7.Post-operative management.
The post operative management and programme of rehabilitation will depend on the acetabular side of the revision procedure. As far as the femoral stem is concerned, full weight bearing can commence as soon as patient comfort will allow.

Summary