A 10-year experience of radiosurgical treatment for cerebral arteriovenous malformations: a perspective from a series with large malformations

2011 ◽  
Vol 115 (2) ◽  
pp. 337-346 ◽  
Author(s):  
Gisela Murray ◽  
Ricardo H. Brau
Keyword(s):  
Puerto Rico ◽  
Arteriovenous Malformations ◽  
Demographic Data ◽  
Latency Period ◽  
Senior Author ◽  
Neurological Deficits ◽  
Bivariate Analysis ◽  
Median Volume ◽  
Lost To Follow Up

Object The purpose of this study was to describe a 10-year experience in the use of radiosurgery (RS) for patients with arteriovenous malformations (AVMs) in Puerto Rico. Methods This retrospective analysis was performed for all patients with AVMs treated with RS by the senior author (R.H.B.) in Puerto Rico. Between February 1999 and December 2009, a total of 83 patients underwent the procedure. All charts were reviewed for recollection of demographic data, and AVM and treatment characteristics. Clinical and radiographic follow-up information was collected retrospectively. Results Eighty-three patients were treated and 86 RS procedures for AVMs were performed during a 10-year period. Eight patients were lost to follow-up. The remaining 75 patients included 36 males and 39 females, whose median age was 34.5 years. Hemorrhage was the initial presentation in 40% of patients. Fifty-seven AVMs (73%) were treated previously with endovascular neurosurgery, without success. The median volume of the malformation was 17.7 ml. Nearly 65% of the malformations were considered large (≥ 10 ml) in volume. Forty patients had AVMs with largest diameter ≥ 3.5 cm. The overall obliteration rate was 56.4%, and the median time for obliteration was 29 months. The AVMs ≥ 3.5 cm in diameter had a greater latency period than those < 3.5 cm (31 months vs 46 months, respectively; p = 0.01). In addition, AVM obliteration was inversely associated with its volume, especially in large lesions (p = 0.037). In bivariate analysis, patients achieving obliteration had lower Spetzler-Martin scores compared with patients in whom obliteration was not achieved (p = 0.009). Postradiosurgery hemorrhages were seen in 9 cases. Eleven patients underwent surgery after RS. Major neurological deficits developed in 9 patients, whereas 17 had only minor deficits. The occurrence of neurological deficits was significantly associated with lesions with volume ≥ 10 ml. Conclusions Radiosurgery is a reasonable treatment option for AVMs in the majority of cases, in spite of the large, difficult-to-treat malformations.

scholarly journals Gamma Knife surgery for incidental cerebral arteriovenous malformations

2014 ◽  
Vol 121 (5) ◽  
pp. 1015-1021 ◽  
Author(s):  
Chun-Po Yen ◽  
Dale Ding ◽  
Ching-Hsiao Cheng ◽  
Robert M. Starke ◽  
Mark Shaffrey ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Latency Period ◽  
Invasive Procedure ◽  
Gamma Knife Surgery ◽  
Neurological Deficits ◽  
Cerebral Arteriovenous Malformations ◽  
Long Term Follow Up

Object A relatively benign natural course of unruptured cerebral arteriovenous malformations (AVMs) has recently been recognized, and the decision to treat incidentally found AVMs has been questioned. This study aims to evaluate the long-term imaging and clinical outcomes of patients with asymptomatic, incidentally discovered AVMs treated with Gamma Knife surgery (GKS). Methods Thirty-one patients, each with an incidentally diagnosed AVM, underwent GKS between 1989 and 2009. The nidus volumes ranged from 0.3 to 11.1 cm3 (median 3.2 cm3). A margin dose between 15 and 26 Gy (median 20 Gy) was used to treat the AVMs. Four patients underwent repeat GKS for still-patent AVM residuals after the initial GKS procedure. Clinical follow-up ranged from 24 to 196 months, with a mean of 78 months (median 51 months) after the initial GKS. Results Following GKS, 19 patients (61.3%) had a total AVM obliteration on angiography. In 7 patients (22.6%), no flow voids were observed on MRI but angiographic confirmation was not available. In 5 patients (16.1%), the AVMs remained patent. A small nidus volume was significantly associated with increased AVM obliteration rate. Thirteen patients (41.9%) developed radiation-induced imaging changes: 11 were asymptomatic (35.5%), 1 had only headache (3.2%), and 1 developed seizure and neurological deficits (3.2%). Two patients each had 1 hemorrhage during the latency period (116.5 risk years), yielding an annual hemorrhage rate of 1.7% before AVM obliteration. Conclusions The decision to treat asymptomatic AVMs, and if so, which treatment approach to use, remain the subject of debate. GKS as a minimally invasive procedure appears to achieve a reasonable outcome with low procedure-related morbidity. In those patients with incidental AVMs, the benefits as well as the risks of radiosurgical intervention will only be fully defined with long-term follow-up.

Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm

2017 ◽  
Vol 10 (3) ◽  
pp. 258-267 ◽  
Author(s):  
John D Nerva ◽  
Jason Barber ◽  
Michael R Levitt ◽  
Jason K Rockhill ◽  
Danial K Hallam ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Complication Rate ◽  
Arteriovenous Malformations ◽  
Treatment Algorithm ◽  
Latency Period ◽  
Neurological Deficits ◽  
Brain Arteriovenous Malformations ◽  
Radiographic Outcomes ◽  
Ethylene Copolymer

BackgroundEmbolization before stereotactic radiosurgery (SRS) for brain arteriovenous malformations (BAVMs) is controversial.ObjectiveTo compare clinical and radiographic outcomes in patients undergoing pre-SRS embolization with ethylene copolymer (Onyx) with outcomes in patients undergoing SRS alone.MethodsSeventy consecutive patients with BAVMs who underwent SRS were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the factors associated with radiographic obliteration and complication.ResultsForty-one (59%) patients presented without BAVM rupture and 29 (41%) patients presented with rupture. Pre-SRS embolization was used in 20 patients (28.6%; 7 unruptured and 13 ruptured). Twenty-five of 70 (36%) patients sustained a complication from treatment, including 6 (9%) patients with a post-SRS latency period hemorrhage. Ten (14%) patients had persistent neurological deficits after treatment. Functional outcome (as modified Rankin Scale), complication rate, and radiographic obliteration at last follow-up were not significantly different between embolized and non-embolized groups in both unruptured and ruptured BAVMs. For unruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 23% and 73% for non-embolized patients and 20% and 60% for embolized patients, respectively. For ruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 45% and 72% for non-embolized patients and 53% and 82% for embolized patients, respectively.ConclusionPre-SRS embolization with Onyx was not associated with worse clinical or radiographic outcomes than SRS treatment without embolization. Pre-SRS embolization has a low complication rate and can safely be used to target high-risk BAVM features in carefully selected patients destined for SRS.

Late cyst formation following gamma knife surgery of arteriovenous malformations

2005 ◽  
Vol 102 (Special_Supplement) ◽  
pp. 124-127 ◽  
Author(s):  
Hung-Chuan Pan ◽  
Jason Sheehan ◽  
Matei Stroila ◽  
Melita Steiner ◽  
Ladislau Steiner
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Cox Regression ◽  
Cyst Formation ◽  
Senior Author ◽  
Gamma Knife Surgery ◽  
Content Type ◽  
Lost To Follow Up ◽  
Fine Print

Object. The authors present data concerning the development of cysts following gamma knife surgery (GKS) in 1203 consecutive patients with arteriovenous malformations (AVMs) treated by the senior author (L.S.). The cyst was defined as a fluid-filled cavity at the site of a treated AVM. Cases involving regions corresponding to previous hematoma cavities were excluded. The incidence of cyst formation was assessed using magnetic resonance imaging studies performed in 196 cases with more than 10 years of follow up, in 332 cases with 5 to 10 years of follow up, and in 675 cases with less than 5 years of follow up. One hundred five cases were lost to follow-up study. The Cox regression method was used to analyze the factors related to cyst formation. Methods. The incidence of cyst formation in the entire patient population was 1.6 and 3.6% in those undergoing follow-up examination for more than 5 years. Ten of 20 cysts developed between 10 to 23 years, nine between 5 to 10 years, and one in less than 5 years following the treatment. Cyst fluid aspiration, cystoperitoneal shunt placement, or craniotomy were used in three symptomatic cases. Analysis of age, sex, and treatment parameters yielded no significant relationship with cyst formation; however, radiation-induced tissue change following GKS (p = 0.027) and prior embolization (p = 0.011) were related to cyst formation. Conclusions. Overall, the incidence of cyst formation in patients who underwent GKS for AVM was 1.6%. The development of the cyst was related to the duration of the follow-up period. When cysts are symptomatic, surgical intervention should be performed.

Stereotactic radiosurgery for arteriovenous malformations, Part 5: management of brainstem arteriovenous malformations

2012 ◽  
Vol 116 (1) ◽  
pp. 44-53 ◽  
Author(s):  
Hideyuki Kano ◽  
Douglas Kondziolka ◽  
John C. Flickinger ◽  
Huai-che Yang ◽  
Thomas J. Flannery ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Radiation Effects ◽  
Latency Period ◽  
Target Volume ◽  
Neurological Deficits ◽  
Latency Interval ◽  
Brain Avms

Object In this paper, the authors' goal was to define the long-term outcomes and risks of stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) of the medulla, pons, and midbrain. Methods Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 67 patients had AVMs in the brainstem. In this series, 51 patients (76%) had a prior hemorrhage. The median target volume was 1.4 cm3 (range 0.1–13.4 cm3). The median margin dose was 20 Gy (range 14–25.6 Gy). Results Obliteration of the AVMs was eventually documented in 35 patients at a median follow-up of 73 months (range 6–269 months). The actuarial rates of documentation of total obliteration were 41%, 70%, 70%, and 76% at 3, 4, 5, and 10 years, respectively. Higher rates of AVM obliteration were associated only with a higher margin dose. Four patients (6%) suffered a hemorrhage during the latency period, and 2 patients died. The rate of AVM hemorrhage after SRS was 3.0%, 3.0%, and 5.8% at 1, 5, and 10 years, respectively. The overall annual hemorrhage rate was 1.9%. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 7 patients (10%) after SRS, and a delayed cyst developed in 2 patients (3%). One patient died at an outside institution with symptoms of AREs and unrecognized hydrocephalus. Higher 12-Gy volumes and higher Spetzler-Martin grades were associated with a higher risk of symptomatic AREs. Ten of 22 patients who had ocular dysfunction before SRS had improvement, 9 were unchanged, and 3 were worse due to AREs. Eight of 14 patients who had hemiparesis before SRS improved, 5 were unchanged, and 1 was worse. Conclusions Although hemorrhage after obliteration did not occur in this series, patients remained at risk during the latency interval until obliteration occurred. Thirty-eight percent of the patients who had neurological deficits due to prior hemorrhage improved. Higher dose delivery in association with conformal and highly selective SRS is required for safe and effective radiosurgery.

Late cyst formation following gamma knife surgery of arteriovenous malformations

2005 ◽  
Vol 102 ◽  
pp. 124-127 ◽  
Author(s):  
Hung-Chuan Pan ◽  
Jason Sheehan ◽  
Matei Stroila ◽  
Melita Steiner ◽  
Ladislau Steiner
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Cox Regression ◽  
Cyst Formation ◽  
Senior Author ◽  
Gamma Knife Surgery ◽  
Content Type ◽  
Lost To Follow Up ◽  
Fine Print

Object.The authors present data concerning the development of cysts following gamma knife surgery (GKS) in 1203 consecutive patients with arteriovenous malformations (AVMs) treated by the senior author (L.S.). The cyst was defined as a fluid-filled cavity at the site of a treated AVM. Cases involving regions corresponding to previous hematoma cavities were excluded. The incidence of cyst formation was assessed using magnetic resonance imaging studies performed in 196 cases with more than 10 years of follow up, in 332 cases with 5 to 10 years of follow up, and in 675 cases with less than 5 years of follow up. One hundred five cases were lost to follow-up study. The Cox regression method was used to analyze the factors related to cyst formation.Methods.The incidence of cyst formation in the entire patient population was 1.6 and 3.6% in those undergoing follow-up examination for more than 5 years. Ten of 20 cysts developed between 10 to 23 years, nine between 5 to 10 years, and one in less than 5 years following the treatment. Cyst fluid aspiration, cystoperitoneal shunt placement, or craniotomy were used in three symptomatic cases. Analysis of age, sex, and treatment parameters yielded no significant relationship with cyst formation; however, radiation-induced tissue change following GKS (p = 0.027) and prior embolization (p = 0.011) were related to cyst formation.Conclusions.Overall, the incidence of cyst formation in patients who underwent GKS for AVM was 1.6%. The development of the cyst was related to the duration of the follow-up period. When cysts are symptomatic, surgical intervention should be performed.

Microsurgical resection of medullary cavernoma via the olivary zone by the retrosigmoid supracondylar approach

2019 ◽  
Vol 1 (2) ◽  
pp. V7
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Helmut Bertalanffy
Keyword(s):  
Cavernous Malformation ◽  
Cleavage Plane ◽  
Foramen Magnum ◽  
Senior Author ◽  
Neurological Deficits ◽  
Lateral Part ◽  
Sitting Position ◽  
Brainstem Cavernoma ◽  
Microsurgical Resection

Microsurgical resection of the medullary cavernoma is rare, comprising less than 15% of more than 250 surgeries of brainstem cavernoma performed by the senior author (H.B.).1 This video demonstrates a case of a cavernous malformation inside the lateral part of the medulla, which was surgically treated via the olivary zone by the retrosigmoid supracondylar approach in a half-sitting position. Osseous drilling of the lateral foramen magnum provided wide exposure of the cerebellomedullary cistern around the olive.2,3 The lesion was completely dissected at the appropriate cleavage plane from the normal parenchyma. The patient developed no new neurological deficits and had no recurrence during 3 years of follow-up after the operation.The video can be found here: https://youtu.be/7i7SccS5HmU.

Fractionated Stereotactic Radiotherapy For the Treatment of Large Arteriovenous Malformations with or without Previous Partial Embolization

Neurosurgery ◽  
2004 ◽  
Vol 55 (3) ◽  
pp. 519-531 ◽  
Author(s):  
Erol Veznedaroglu ◽  
David W. Andrews ◽  
Ronald P. Benitez ◽  
M. Beverly Downes ◽  
Maria Werner-Wasik ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Stereotactic Radiotherapy ◽  
Arteriovenous Malformations ◽  
Three Dimensional ◽  
Late Complications ◽  
Fractionated Stereotactic Radiotherapy ◽  
Medical Systems ◽  
Significant Treatment ◽  
Lost To Follow Up

Abstract OBJECTIVE: Despite the success of stereotactic radiosurgery, large inoperable arteriovenous malformations (AVMs) of 14 cm3 or more have remained largely refractory to stereotactic radiosurgery, with much lower obliteration rates. We review treatment of large AVMs either previously untreated or partially obliterated by embolization with fractionated stereotactic radiotherapy (FSR) regimens using a dedicated linear accelerator (LINAC). METHODS: Before treatment, all patients were discussed at a multidisciplinary radiosurgery board and found to be suitable for FSR. All patients were evaluated for pre-embolization. Those who had feeding pedicles amenable to glue embolization were treated. LINAC technique involved acquisition of a stereotactic angiogram in a relocatable frame that was also used for head localization during treatment. The FSR technique involved the use of six 7-Gy fractions delivered on alternate days over a 2-week period, and this was subsequently dropped to 5-Gy fractions after late complications in one of seven patients treated with 7-Gy fractions. Treatments were based exclusively on digitized biplanar stereotactic angiographic data. We used a Varian 600SR LINAC (Varian Medical Systems, Inc., Palo Alto, CA) and XKnife treatment planning software (Radionics, Inc., Burlington, MA). In most cases, one isocenter was used, and conformality was established by non-coplanar arc beam shaping and differential beam weighting. RESULTS: Thirty patients with large AVMs were treated between January 1995 and August 1998. Seven patients were treated with 42-Gy/7-Gy fractions, with one patient lost to follow-up and the remaining six with previous partial embolization. Twenty-three patients were treated with 30-Gy/5-Gy fractions, with two patients lost to follow-up and three who died as a result of unrelated causes. Of 18 evaluable patients, 8 had previous partial embolization. Mean AVM volumes at FSR treatment were 23.8 and 14.5 cm3, respectively, for the 42-Gy/7-Gy fraction and 30-Gy/5-Gy fraction groups. After embolization, 18 patients still had AVM niduses of 14 cm3 or more: 6 in the 7-Gy cohort and 12 in the 5-Gy cohort. For patients with at least 5-year follow-up, angiographically documented AVM obliteration rates were 83% for the 42-Gy/7-Gy fraction group, with a mean latency of 108 weeks (5 of 6 evaluable patients), and 22% for the 30-Gy/5-Gy fraction group, with an average latency of 191 weeks (4 of 18 evaluable patients) (P = 0.018). For AVMs that remained at 14 cm3 or more after embolization (5 of 6 patients), the obliteration rate remained 80% (4 of 5 patients) for the 7-Gy cohort and dropped to 9% for the 5-Gy cohort. A cumulative hazard plot revealed a 7.2-fold greater likelihood of obliteration with the 42-Gy/7-Gy fraction protocol (P = 0.0001), which increased to a 17-fold greater likelihood for postembolization AVMs of 14 cm3 or more (P = 0.003). CONCLUSION: FSR achieves obliteration for AVMs at a threshold dose, including large residual niduses after embolization. With significant treatment-related morbidities, further investigation warrants a need for better three-dimensional target definition with higher dose conformality.

scholarly journals Adenosine-induced Asystole during AVM Embolization

2021 ◽  
Author(s):  
V. Hellstern ◽  
P. Bhogal ◽  
M. Aguilar Pérez ◽  
M. Alfter ◽  
A. Kemmling ◽  
...  
Keyword(s):  
Demographic Data ◽  
Clinical Results ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Residual Shunt ◽  
Grade 5 ◽  
Martin Grade ◽  
Grade 3 ◽  
Brain Avms

Abstract Background Adenosine induced cardiac standstill has been used intraoperatively for both aneurysm and arteriovenous malformation (AVM) surgery and embolization. We sought to report the results of adenosine induced cardiac standstill as an adjunct to endovascular embolization of brain AVMs. Material and Methods We retrospectively identified patients in our prospectively maintained database to identify all patients since January 2007 in whom adenosine was used to induce cardiac standstill during the embolization of a brain AVM. We recorded demographic data, clinical presentation, Spetzler Martin grade, rupture status, therapeutic intervention and number of embolization sessions, angiographic and clinical results, clinical and radiological outcomes and follow-up information. Results We identified 47 patients (22 female, 47%) with average age 42 ± 17 years (range 6–77 years) who had undergone AVM embolization procedures using adjunctive circulatory standstill with adenosine. In total there were 4 Spetzler Martin grade 1 (9%), 9 grade 2 (18%), 15 grade 3 (32%), 8 grade 4 (18%), and 11 grade 5 (23%) lesions. Of the AVMs six were ruptured or had previously ruptured. The average number of embolization procedures per patient was 5.7 ± 7.6 (range 1–37) with an average of 2.6 ± 2.2 (range 1–14) embolization procedures using adenosine. Overall morbidity was 17% (n = 8/47) and mortality 2.1% (n = 1/47), with permanent morbidity seen in 10.6% (n = 5/47) postembolization. Angiographic follow-up was available for 32 patients with no residual shunt seen in 26 (81%) and residual shunts seen in 6 patients (19%). The angiographic follow-up is still pending in 14 patients. At last follow-up 93.5% of patients were mRS ≤2 (n = 43/46). Conclusion Adenosine induced cardiac standstill represents a viable treatment strategy in high flow AVMs or AV shunts that carries a low risk of mortality and permanent neurological deficits.

scholarly journals Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes

2014 ◽  
Vol 14 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Matthew B. Potts ◽  
Sunil A. Sheth ◽  
Jonathan Louie ◽  
Matthew D. Smyth ◽  
Penny K. Sneed ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Target Volume ◽  
Neurological Deficits ◽  
Single Institution ◽  
Risks And Benefits ◽  
Scale Scores ◽  
Time Of Presentation

Object Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. Methods The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. Results A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm3 (range 0.09–62.3 cm3), and median prescription marginal dose used was 17.5 Gy (range 12–20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18–20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%–37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0–2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. Conclusions A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.

Cement-in-cement femoral component revision

2021 ◽  
Vol 103-B (7) ◽  
pp. 1215-1221
Author(s):  
John W. Kennedy ◽  
Nigel Y. B. Ng ◽  
David Young ◽  
Nicholas Kane ◽  
Andrew G. Marsh ◽  
...  
Keyword(s):  
Femoral Component ◽  
Short Form ◽  
Demographic Data ◽  
Senior Author ◽  
Inclusion Criteria ◽  
Reliable Technique ◽  
Patient Demographic Data ◽  
Oxford Hip Score ◽  
Component Revision

Aims Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components. Methods From our prospectively collated database, we identified all patients undergoing cement-in-cement revision from January 2005 to January 2013 who had a minimum of two years' follow-up. All cases were performed by the senior author using either an Exeter short revision stem or the C-Stem AMT high offset No. 1 prosthesis. Patients were followed-up annually with clinical and radiological assessment. Results A total of 97 patients matched the inclusion criteria (50 Exeter and 47 C-Stem AMT components). There were no significant differences between the patient demographic data in either group. Mean follow-up was 9.7 years. A significant improvement in Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-item Short-Form Survey (SF-12) scores was observed in both cohorts. Leg lengths were significantly shorter in the Exeter group, with a mean of -4 mm in this cohort compared with 0 mm in the C-Stem AMT group. One patient in the Exeter group had early evidence of radiological loosening. In total, 16 patients (15%) underwent further revision of the femoral component (seven in the C-Stem AMT group and nine in the Exeter group). No femoral components were revised for aseptic loosening. There were two cases of femoral component fracture in the Exeter group. Conclusion Our series shows promising mid-term outcomes for the cement-in-cement revision technique using either the Exeter or C-Stem AMT components. These results demonstrate that cement-in-cement revision using a double or triple taper-slip design is a safe and reliable technique when used for the correct indications. Cite this article: Bone Joint J 2021;103-B(7):1215–1221.

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