The posterior approach reduces the risk of thin cement mantles with a straight femoral stem design

Background and purpose The properties of the cement mantle around a prosthesis are important. We investigated whether the surgical approach to the hip influences the quality and thickness of the cement mantle when using a straight femoral stem design.

Methods In a consecutive multi-surgeon series, we reviewed the radiographs of 270 patients after cemented Exeter total hip arthroplasty. 135 stems were introduced using an antero-lateral (transgluteal) approach and 135 stems were introduced using a posterior approach. Anterior-posterior and lateral radiographs were reviewed and cement mantle thickness was measured in Gruen zones 1–14. We graded cement mantle quality according to the Barrack classification.

Results Barrack grading did not reveal any difference in cement mantle quality between the two groups. AP and lateral radiographs showed no difference in stem alignment between the groups. The risk of a thin cement mantle (< 2 mm) was lower with a posterior approach (OR = 1.8, 95% CI: 1–3; p = 0.03). The greatest risk of a cement mantle thickness of < 2 mm occurred in Gruen zones 8–9 regardless of the surgical approach used.

Interpretation With a straight femoral stem design, the posterior approach to the hip joint appears to give a lower risk of a thin cement mantle. Irrespective of the approach, there was a risk of thin cement mantles in Gruen zones 8 and 9, which highlights the importance of lateral radiographs in the postoperative radiographic assessment of total hip replacements.