In summary, our mid-term results show comparable outcomes for both approaches regarding functionality, pain, quality of life and daily activity.

Intraoperative fat embolism associated with cemented total hip arthroplasty is a well recognized complication. In a new sheep model allowing for standardized bilateral, simultaneous cement pressurization we studied the effectiveness of both pulsatile and syringe lavage of equal volume with regard to their cleansing capabilities as measured by fat and bone marrow intravasation. The operative procedure involved bilateral placement of intravenous catheters into the external iliac veins via retroperitoneal approach. After femoral neck osteotomies both femoral cavities were prepared for retrograde cement application. After randomization one side was lavaged with 250 ml irrigation using a bladder syringe, the contralateral femur with the identical volume but using a pulsatile lavage. A specially designed apparatus was used to allow for bilateral simultaneous cement pressurization. Venous blood from both iliac catheters was then collected, anticoagulated and a quantitative and qualitative fat analysis was performed. Despite equal volume manual lavage produced significantly higher fat and bone marrow intravasation (P < 0.001) than pulsatile lavage thus suggesting that not only the volume but also the quality of bone lavage is an essential factor influencing the risk of fat embolism and adverse cardiorespiratory effects. Our findings further emphasize the important role of pulsatile lavage in preventing fat and bone marrow embolisation during cemented total hip arthroplasty.