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Boyle AB, Kuperus T, Maheno T, Frampton C, Vane A, Poutawera V. Equivalent revision rates and patient reported outcomes with routine use of a short (125mm) cemented stem for total hip arthroplasty compared to a standard length (150mm) cemented stem. A two surgeon series of 1335 patients. Arch Orthop Trauma Surg 2024; 144:2019-2026. [PMID: 38581441 DOI: 10.1007/s00402-024-05235-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/15/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Routine total hip arthroplasty (THA) using a short cemented stem as compared with a standard length cemented stem may have benefits in terms of stress distribution, bone preservation, stem subsidence and ease of revision surgery. Two senior arthroplasty surgeons transitioned their routine femoral implant from a standard 150 mm Exeter V40 cemented stem to a short 125 mm Exeter V40 cemented stem for all patients over the course of several years. We analysed revision rates, adjusted survival, and PROMS scores for patients who received a standard stem and a short stem in routine THA. METHODS All THAs performed by the two surgeons between January 2011 and December 2021 were included. All procedures were performed using either a 150 mm or 125 mm Exeter V40 stem. Demographic data, acetabular implant type, and outcome data including implant survival, reason for revision, and post-operative Oxford Hip Scores were obtained from the New Zealand Joint Registry (NZJR), and detailed survival analyses were performed. Primary outcome was revision for any reason. Reason for revision, including femoral or acetabular failure, and time to revision were also recorded. RESULTS 1335 THAs were included. 516 using the 150 mm stem and 819 using the 125 mm stem. There were 4055.5 and 3227.8 component years analysed in the standard stem and short stem groups respectively due to a longer mean follow up in the 150 mm group. Patient reported outcomes were comparable across all groups. Revision rates were comparable between the standard 150 mm stem (0.44 revisions/100 component years) and the short 125 mm stem (0.56 revisions/100 component years) with no statistically significant difference found (p = 0.240). CONCLUSION Routine use of a short 125 mm stem had no statistically significant impact on revision rate or PROMS scores when compared to a standard 150 mm stem. There may be benefits to routine use of a short cemented femoral implant.
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Affiliation(s)
- Alex B Boyle
- Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, Private Bag 12024, Tauranga, 3143, New Zealand.
| | - Tom Kuperus
- Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, Private Bag 12024, Tauranga, 3143, New Zealand
| | - Teriana Maheno
- Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, Private Bag 12024, Tauranga, 3143, New Zealand
| | - Chris Frampton
- Department of Medicine, The University of Otago, Christchurch, New Zealand
| | - Andrew Vane
- Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, Private Bag 12024, Tauranga, 3143, New Zealand
| | - Vaughan Poutawera
- Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, Private Bag 12024, Tauranga, 3143, New Zealand
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Jain S, Lamb JN, Drake R, Entwistle I, Baren JP, Thompson Z, Beadling AR, Bryant MG, Shuweihdi F, Pandit H. Risk factors for periprosthetic femoral fracture risk around a cemented polished taper-slip stem using an osteoporotic composite bone model. Proc Inst Mech Eng H 2024; 238:324-331. [PMID: 38235693 DOI: 10.1177/09544119231225172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
This biomechanical study aimed to determine if variations in stem material, stem geometry, stem offset and cement viscosity affect mechanical resistance to postoperative periprosthetic fracture (PFF) after hip arthroplasty with a commonly used cemented polished taper-slip (PTS) stem (CPT, Zimmer Biomet) in a novel osteoporotic composite femoral bone model. Thirty-six osteoporotic composite femoral models were tested using a standardised in-vitro loading technique to simulate a typical PFF. Outcome measures were torque to failure (N), fracture energy (N/m2) and rotation to failure (°). Comparisons were made by stem material (cobalt chrome vs stainless steel), stem geometry (CPT stem vs Exeter stem), stem offset (standard offset vs extra extended offset) and cement viscosity (high viscosity vs low viscosity). Statistical comparisons were carried out with significance set at p < 0.05. All tested samples produced clinically representative fracture patterns with varying degrees of bone and cement comminution. There was no statistically significant difference in torque to failure, fracture energy or rotation to failure between any of the compared variables (all p > 0.05). This is the first biomechanical study on mechanical resistance to PFF using osteoporotic composite bone models. For the CPT stem, it confirms that stem material, stem offset, stem geometry and cement viscosity do not affect mechanical resistance to PFF in an osteoporotic bone model.
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Affiliation(s)
- Sameer Jain
- Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Jonathan N Lamb
- Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Ruth Drake
- Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ian Entwistle
- Department of Radiography, University of Bradford, Bradford, UK
| | - James P Baren
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Zachary Thompson
- School of Mechanical Engineering, University of Leeds, Leeds, UK
| | | | - Michael G Bryant
- School of Mechanical Engineering, University of Leeds, Leeds, UK
| | | | - Hemant Pandit
- Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Wakama H, Okamoto Y, Okayoshi T, Ikeda K, Matsuyama J, Otsuki S, Neo M. Unfavorable cortical hypertrophy potentially predisposes to periprosthetic "axe splitter" fracture in a collarless polished curved triple-tapered cemented stem: The time-dependent radiographic change in five SC-stem cases. J Orthop Sci 2024; 29:439-444. [PMID: 36182639 DOI: 10.1016/j.jos.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/20/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The periprosthetic fracture of cemented polished tapered stems is occasionally called a "unique" or "axe splitter" fracture. However, there has been insufficient evidence regarding the association between the radiographic findings prior to incidence and this cumbersome fracture. To determine if there are any radiographic interpretations associated with this fracture pattern, we report the five SC-stem cases with total hip arthroplasty. METHODS We investigate the patient characteristics and serial radiographs of five fracture cases and evaluate the time-dependent specific radiographical changes around the stem between pre-arthroplasty and fracture. RESULTS Fractures developed at 3.5-6.4 years after surgery with low-grade injury or with no particular incentive. Femoral cortical hypertrophy at the distal medial side around the stem was observed in all cases before the development of fractures, at 2-6 years after primary surgery. The duration between cortical hypertrophy appearance to the development of fracture was 0.4-3.1 years. CONCLUSIONS The appearance of this zone-specific cortical hypertrophy might play a key role in the occurrence of periprosthetic fractures. Further studies with larger sample sizes should be conducted to elucidate this eccentric periprosthetic fracture.
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Affiliation(s)
- Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan.
| | - Yoshinori Okamoto
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Tomohiro Okayoshi
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Kuniaki Ikeda
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Junya Matsuyama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
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4
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Jain S, Lamb JN, Pandit H. Cemented femoral stem design and postoperative periprosthetic fracture risk following total hip arthroplasty. Bone Joint J 2024; 106-B:11-15. [PMID: 38160687 DOI: 10.1302/0301-620x.106b1.bjj-2023-0587.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.
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Affiliation(s)
- Sameer Jain
- Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | | | - Hemant Pandit
- Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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5
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Oe K, Iida H, Hirata M, Kawamura H, Ueda N, Nakamura T, Okamoto N, Saito T. An atypical periprosthetic fracture in collarless, polished, tapered, cemented stems of total hip arthroplasty: A report of five SC-stem cases and literature review. J Orthop Sci 2023; 28:1422-1429. [PMID: 34045138 DOI: 10.1016/j.jos.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/29/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Kenichi Oe
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan.
| | - Hirokazu Iida
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
| | - Masayuki Hirata
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
| | - Hiroshi Kawamura
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
| | - Narumi Ueda
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
| | - Tomohisa Nakamura
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
| | - Naofumi Okamoto
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
| | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
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6
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Sattar A, Kärrholm J, Möller M, Chatziagorou G. Fracture pattern and risk factors for reoperation after treatment of 156 periprosthetic fractures around an anatomic cemented hip stem. Acta Orthop 2023; 94:438-446. [PMID: 37593786 PMCID: PMC10436285 DOI: 10.2340/17453674.2023.18263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 06/29/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND AND PURPOSE The Lubinus SP2 stem has been associated with a very low risk of periprosthetic femoral fractures (PPFFs). We aimed, primarily, to study the radiographic morphology of PPFFs close to a Lubinus SP2 stem. Secondarily, we analyzed whether higher reoperation rate was correlated to the revision method chosen or to the characteristics of the fracture and of the bone. PATIENTS AND METHODS The study included 156 femoral fractures close to a Lubinus cemented stem. These fractures were treated in 40 hospitals in Sweden between 2006 and 2011 and were followed up until 2019. Data from the Swedish Arthroplasty Register was used. Medical records and radiographs were studied. The fractures were classified according to the Vancouver classification. The fracture location and anatomy were delineated. We also measured the remaining attachment index (RAI) and the canal thickness ratio. RESULTS Vancouver type C (n = 101) and spiral fractures (n = 67, 41 in Vancouver C and 26 in Vancouver B) were the most common fracture types. 4 fractures were avulsion of the greater trochanter. The remaining 51 fractures occurred around the stem (B1: 25, B2: 16, and B3: 10). B fractures were more commonly reoperated on (18 of 51, 35%) than type C fractures (11 of 101, 11%, P = 0.001). In most femurs with type B3 fracture, the fracture line covered an area only around the stem, but in all B1 and in 11 of 16 B2 fractures, it was extended even distal to the stem. ORIF instead of stem revision in B2 fractures, use of short stems or plates, and inadequate reduction of the fractures were risk factors for subsequent reoperations. CONCLUSION The higher reoperation rate in type B fractures, compared with fractures distal to the stem, could be caused by their higher degree of complexity and reduced capacity for healing in the region around the stem.
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Affiliation(s)
- Ali Sattar
- Department of Orthopaedics, Alingsås Hospital, Alingsås.
| | - Johan Kärrholm
- The Swedish Arthroplasty Register, Gothenburg; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Michael Möller
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Georgios Chatziagorou
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg
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Kaneuji A, Chen M, Takahashi E, Takano N, Fukui M, Soma D, Tachi Y, Orita Y, Ichiseki T, Kawahara N. Collarless Polished Tapered Stems of Identical Shape Provide Differing Outcomes for Stainless Steel and Cobalt Chrome: A Biomechanical Study. J Funct Biomater 2023; 14:jfb14050262. [PMID: 37233372 DOI: 10.3390/jfb14050262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/24/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023] Open
Abstract
Cemented polished tapered femoral stems (PTS) made of cobalt-chrome alloy (CoCr) are a known risk factor for periprosthetic fracture (PPF). The mechanical differences between CoCr-PTS and stainless-steel (SUS) PTS were investigated. CoCr stems having the same shape and surface roughness as the SUS Exeter® stem were manufactured and dynamic loading tests were performed on three each. Stem subsidence and the compressive force at the bone-cement interface were recorded. Tantalum balls were injected into the cement, and their movement was tracked to indicate cement movement. Stem motions in the cement were greater for the CoCr stems than for the SUS stems. In addition, although we found a significant positive correlation between stem subsidence and compressive force in all stems, CoCr stems generated a compressive force over three times higher than SUS stems at the bone-cement interface with the same stem subsidence (p < 0.01). The final stem subsidence amount and final force were greater in the CoCr group (p < 0.01), and the ratio of tantalum ball vertical distance to stem subsidence was significantly smaller for CoCr than for SUS (p < 0.01). CoCr stems appear to move more easily in cement than SUS stems, which might contribute to the increased occurrence of PPF with the use of CoCr-PTS.
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Affiliation(s)
- Ayumi Kaneuji
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Mingliang Chen
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
- Department of Orthopaedics, Affiliated Renhe Hospital of China Three Gorges University, Yichang 443000, China
| | - Eiji Takahashi
- Department of Orthopaedics, Affiliated Renhe Hospital of China Three Gorges University, Yichang 443000, China
| | - Noriyuki Takano
- Department of Mechanical Engineering, Kanazawa Institution of Technology, Nonoichi 921-8501, Japan
| | - Makoto Fukui
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Daisuke Soma
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Yoshiyuki Tachi
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Yugo Orita
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Toru Ichiseki
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Norio Kawahara
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
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8
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Lamb JN, Coltart O, Adekanmbi I, Pandit HG, Stewart T. Comparison of axial-rotational postoperative periprosthetic fracture of the femur in composite osteoporotic femur versus human cadaveric specimens: A validation study. Proc Inst Mech Eng H 2022; 236:973-978. [PMID: 35603754 PMCID: PMC9289970 DOI: 10.1177/09544119221092842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Postoperative periprosthetic femoral fracture following hip replacement has been the subject of many varied experimental approaches. Cadaveric samples offer realistic fit and fracture patterns but are subject to large between-sample variation. Composite femurs have not yet been validated for this purpose. We compared the results of composite femurs to cadaveric femurs using an established methodology. In vitro postoperative periprosthetic fracture results using axial-rotational loading were compared between 12 composite femurs and nine fresh frozen femurs, which were implanted with an otherwise identical collarless (6 composite vs 4 cadaveric) or collared (6 composite vs 5 cadaveric) cementless femoral stem using identical methodology. Fracture torque and rotational displacement were measured and torsional stiffness and rotational work prior to fracture were estimated. Fractures patterns were graded according to the Unified Classification System. Fracture torque, displacement, torsional stiffness and fracture patterns for cadaveric and composite femurs were similar between groups. There was a trend for a greater rotational displacement in the cadaveric groups, which lead to a decrease in torsional stiffness and a significantly greater rotational work prior to fracture for all cadaveric specimens (collarless stems: 10.51 [9.71 to 12.57] vs 5.21 [4.25 to 6.04], p = 0.01 and for collared stems: 15.38 [14.01 to 17.05] vs 5.76 [4.92 to 6.64], p = 0.01). Given comparable fracture torque and the similarity in fracture patterns for fracture trials using composite samples versus cadaveric femurs, the use of composite femur models may be a reasonable choice for postoperative periprosthetic femoral fracture studies within certain limitations.
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Affiliation(s)
- Jonathan N Lamb
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of medicine, University of Leeds, Leeds, UK
| | - Oliver Coltart
- School of Mechanical Engineering, University of Leeds, Leeds, UK
| | | | - Hemant G Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of medicine, University of Leeds, Leeds, UK
| | - Todd Stewart
- School of Mechanical Engineering, University of Leeds, Leeds, UK
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9
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Femur Strength is Similar Before and After Iatrogenic Fracture During Total Hip Arthroplasty: A Biomechanical Analysis. Arthroplast Today 2022; 15:47-54. [PMID: 35399985 PMCID: PMC8987314 DOI: 10.1016/j.artd.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/16/2022] [Accepted: 02/12/2022] [Indexed: 11/20/2022] Open
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10
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Takegami Y, Seki T, Osawa Y, Imagama S. Comparison of periprosthetic femoral fracture torque and strain pattern of three types of femoral components in experimental model. Bone Joint Res 2022; 11:270-277. [PMID: 35514237 PMCID: PMC9130673 DOI: 10.1302/2046-3758.115.bjr-2021-0375.r2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS Periprosthetic hip fractures (PPFs) after total hip arthroplasty are difficult to treat. Therefore, it is important to identify modifiable risk factors such as stem selection to reduce the occurrence of PPFs. This study aimed to clarify differences in fracture torque, surface strain, and fracture type analysis between three different types of cemented stems. METHODS We conducted biomechanical testing of bone analogues using six cemented stems of three different types: collarless polished tapered (CPT) stem, Versys Advocate (Versys) stem, and Charnley-Marcel-Kerboull (CMK) stem. Experienced surgeons implanted each of these types of stems into six bone analogues, and the analogues were compressed and internally rotated until failure. Torque to fracture and fracture type were recorded. We also measured surface strain distribution using triaxial rosettes. RESULTS There was a significant difference in fracture torque between the three stem types (p = 0.036). Particularly, the median fracture torque for the CPT stem was significantly lower than that for the CMK stem (CPT vs CMK: 164.5 Nm vs 200.5 Nm; p = 0.046). The strain values for the CPT stem were higher than those for the other two stems at the most proximal site. The fracture pattern of the CPT and Versys stems was Vancouver type B, whereas that of the CMK stem was type C. CONCLUSION Our study suggested that the cobalt-chromium alloy material, polished surface finish, acute-square proximal form, and the absence of a collar may be associated with lower fracture torque, which may be related to PPF. Cite this article: Bone Joint Res 2022;11(5):270-277.
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Affiliation(s)
- Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taisuke Seki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Osawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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11
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Gausden EB, Abdel MP, Mabry TM, Berry DJ, Trousdale RT, Sierra RJ. Midterm Results of Primary Exeter Cemented Stem in a Select Patient Population. J Bone Joint Surg Am 2021; 103:1826-1833. [PMID: 33974592 DOI: 10.2106/jbjs.20.01829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most North American surgeons predominantly use uncemented stems in primary total hip arthroplasties (THAs) and reserve cemented stems for selected older patients and those with poor bone quality. However, data on this "selective use" strategy for cemented stems in the population at risk for periprosthetic fracture and implant loosening are limited. The purpose of this study was to describe implant survivorship, complications, and radiographic results of a specific collarless, polished, tapered cemented stem (Exeter; Stryker) used selectively in a predominantly elderly population undergoing primary THA. METHODS We identified 386 patients who underwent a total of 423 primary THAs with selectively utilized Exeter stems for the treatment of osteoarthritis between 2006 and 2017. In the same time period, 11,010 primary THAs were performed with uncemented stems and 961 with non-Exeter cemented stems. The mean patient age was 77 years, 71% were female, and the mean body mass index was 29 kg/m2. Competing risk analysis accounting for death was utilized to determine cumulative incidences of revision and reoperation. The mean follow-up was 5 years (range, 2 to 12 years). RESULTS The 10-year cumulative incidence of any femoral component revision in this patient cohort was 4%, with 10 stems revised at the time of the latest follow-up. There were no intraoperative femoral fractures. The indications for revision were postoperative periprosthetic femoral fracture (n = 6), dislocation (n = 3), and infection (n = 1). There were no revisions for femoral loosening. The 10-year cumulative incidence of reoperation was 10%. The 10-year cumulative incidence of Vancouver B periprosthetic femoral fracture was 2%. Radiographically, there were no cases of aseptic loosening or osteolysis. There was a significant improvement in median Harris hip score, from 53 preoperatively to 92 at a mean follow-up of 5 years (p < 0.001). CONCLUSIONS The strategy of selectively utilizing a collarless, polished, tapered cemented stem produced a low (4%) cumulative incidence of stem revision at 10 years postoperatively and resulted in no cases of aseptic loosening. The use of the Exeter stem did not eliminate postoperative femoral fractures in this predominantly elderly, female patient population. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Elizabeth B Gausden
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tad M Mabry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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12
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Lamb JN, Coltart O, Adekanmbi I, Pandit HG, Stewart T. Calcar-collar contact during simulated periprosthetic femoral fractures increases resistance to fracture and depends on the initial separation on implantation: A composite femur in vitro study. Clin Biomech (Bristol, Avon) 2021; 87:105411. [PMID: 34144390 DOI: 10.1016/j.clinbiomech.2021.105411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND A calcar collar may reduce risk of periprosthetic fracture of the femur, through collar contact. We estimated the effect of collar contact on periprosthetic fracture mechanics using a collared fully coated cementless femoral stem and then estimated the effect of initial calcar-collar separation on the likelihood of collar contact. METHODS Three groups of six composite left femurs with increasing calcar-collar separation in each group, underwent periprosthetic fracture simulation in a materials testing machine. Fracture torque and rotational displacement were measured and torsional stiffness and rotational work prior to fracture were estimated. Calcar collar contact prior to fracture was identified using high speed camera footage. FINDINGS Where calcar-collar contact occurred fracture torque was greater (47.33 [41.03 to 50.45] Nm versus 38.26 [33.70 to 43.60] Nm, p = 0.05), Rotational displacement was less (16.6 [15.5 to 22.3] degrees versus 21.2 [18.9 to 28.1] degrees, p = 0.07), torsional stiffness was greater (151.38 [123.04 to 160.42] rad.Nm-1 versus 96.86 [84.65 to 112.98] rad.Nm-1, p < 0.01) and rotational work was similar (5.88 [4.67, 6.90] J versus 5.31 [4.40, 6.56] J, p = 0.6). Odds ratio (OR) of not achieving collar contact (95% confidence interval) increased 3.8 fold (95% CI 1.6 to 30.2, p < 0.05) for each millimetre of separation in the regression model. 95% chance of collar contact was associated with a separation of 1 mm or less. INTERPRETATION Surgeons should reduce calcar-collar separation at stem implantation to a maximum of 1 mm to increase the chance of calcar-collar contact during injury and reduce the risk of early post-operative femoral fracture.
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Affiliation(s)
- Jonathan N Lamb
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds LS7 4SA, UK.
| | - Oliver Coltart
- School of Mechanical Engineering, University of Leeds, Leeds LS2 9DX, UK
| | - Isaiah Adekanmbi
- DePuy International, Johnson and Johnson, St Anthony's Rd, Leeds LS11 8DT, UK
| | - Hemant G Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds LS7 4SA, UK
| | - Todd Stewart
- School of Mechanical Engineering, University of Leeds, Leeds LS2 9DX, UK
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Biomechanical Comparison of Periprosthetic Femoral Fracture Risk in Three Femoral Components in a Sawbone Model. J Arthroplasty 2021; 36:387-394. [PMID: 32826144 DOI: 10.1016/j.arth.2020.07.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/14/2020] [Accepted: 07/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The increasing use of orthopedic total hip arthroplasty implants has led to a consequent rise in the incidence of associated periprosthetic fractures (PPFs). Analysis of the National Joint Registry data showed the choice of cemented hip stem influenced the risk of a PPF occurring. However, the effect of implant design in relation to the risk of PPFs has not been investigated. METHODS The main objective is to compare the biomechanics of PPFs as a failure of the Exeter V40, CPT, and DePuy C-Stem stems in a composite Sawbone model to identify whether a difference in the risk of fracture exists between them. Twenty-six Sawbones were divided into 3 groups, cemented with the Stryker Exeter, Zimmer CPT, or DePuy C-Stem and then torqued to fracture. RESULTS When compared with the Exeter, the CPT- and C-Stem-implanted Sawbone models would sustain PPFs at a statistically significantly lower rotation to failure (20.1° and 26.7° vs 33.6°, P < .01) and torque to failure (124 Nm and 143 Nm vs 174 Nm, P < .01) values. The energy release rate at failure for the Exeter was significantly higher than that for the CPT and C-Stem (61.2 Nm vs 21.8 Nm and 38.6 Nm, P < .01), which led to more comminution. CONCLUSION The CPT- and C-Stem-implanted femurs, although fracturing earlier, fractured in a simple pattern with less comminution. The differences in stem design mean higher stress at the critical point of failure in the CPT implanted femur compared with the Exeter and DePuy, which is likely the reason behind the observed increased risk of PPFs with the CPT implant.
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14
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Freitag T, Kutzner KP, Bieger R, Reichel H, Ignatius A, Dürselen L. Biomechanics of a cemented short stem: a comparative in vitro study regarding primary stability and maximum fracture load. Arch Orthop Trauma Surg 2021; 141:1797-1806. [PMID: 33755800 PMCID: PMC8437915 DOI: 10.1007/s00402-021-03843-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In total hip arthroplasty, uncemented short stems have been used more and more frequently in recent years. Especially for short and curved femoral implants, bone-preserving and soft tissue-sparing properties are postulated. However, indication is limited to sufficient bone quality. At present, there are no curved short stems available which are based on cemented fixation. METHODS In this in vitro study, primary stability and maximum fracture load of a newly developed cemented short-stem implant was evaluated in comparison to an already well-established cemented conventional straight stem using six pairs of human cadaver femurs with minor bone quality. Primary stability, including reversible micromotion and irreversible migration, was assessed in a dynamic material-testing machine. Furthermore, a subsequent load-to-failure test revealed the periprosthetic fracture characteristics. RESULTS Reversible and irreversible micromotions showed no statistical difference between the two investigated stems. All short stems fractured under maximum load according to Vancouver type B3, whereas 4 out of 6 conventional stems suffered a periprosthetic fracture according to Vancouver type C. Mean fracture load of the short stems was 3062 N versus 3160 N for the conventional stems (p = 0.84). CONCLUSION Primary stability of the cemented short stem was not negatively influenced compared to the cemented conventional stem and no significant difference in fracture load was observed. However, a clear difference in the fracture pattern has been identified.
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Affiliation(s)
- Tobias Freitag
- Department of Orthopaedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Karl Philipp Kutzner
- Department of Orthopaedic Surgery and Traumatology, St. Josefs Hospital Wiesbaden, Beethovenstr. 20, 65189, Wiesbaden, Germany
| | - Ralf Bieger
- Department of Orthopaedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Heiko Reichel
- Department of Orthopaedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, Ulm University, Medical Centre, Helmholtzstr. 14, 89081, Ulm, Germany
| | - Lutz Dürselen
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, Ulm University, Medical Centre, Helmholtzstr. 14, 89081, Ulm, Germany
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15
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Chatterjee S, Roy S, Majumder S, RoyChowdhury A. Biomechanical Analysis to Probe Role of Bone Condition and Subject Weight in Stiffness Customization of Femoral Stem for Improved Periprosthetic Biomechanical Response. J Biomech Eng 2020; 142:101002. [PMID: 32320044 DOI: 10.1115/1.4046973] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Indexed: 11/08/2022]
Abstract
Stress shielding due to difference in stiffness of bone and implant material is one among the foremost causes of loosening and failure of load-bearing implants. Thus far, femoral geometry has been given priority for the customization of total hip joint replacement (THR) implant design. This study, for the first time, demonstrates the key role of bone condition and subject-weight on the customization of stiffness and design of the femoral stem. In particular, internal hollowness was incorporated to reduce the implant stiffness and such designed structure has been customized based on subject parameters, including bone condition and bodyweight. The primary aim was to tailor these parameters to achieve close to natural strain distribution at periprosthetic bone and to reduce interfacial bone loss over time. The maintenance of interfacial bone density over time has been studied here through analysis of bone remodeling (BR). For normal bodyweight, the highest hollowness exhibited clinically relevant biomechanical response, for all bone conditions. However, for heavier subjects, consideration of bone quality was found to be essential as higher hollowness induced bone failure in weaker bones and implant failure in stronger bones. Moreover, for stronger bone, thinner medial wall was found to reduce bone resorption over time on the proximo-lateral zone of stress shielding, while lateral thinning was found advantageous for weaker bones. The findings of this study are likely to facilitate designing of femoral stems for achieving better physiological outcomes and enhancement of the quality of life of patients undergoing THR surgery.
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Affiliation(s)
- Subhomoy Chatterjee
- Department of Aerospace Engineering and Applied Mechanics, Indian Institute of Engineering Science and Technology, Howrah, West Bengal 711103, India; Materials Research Centre, Indian Institute of Science, Bangalore, Karnataka 560012, India
| | - Sandipan Roy
- Department of Aerospace Engineering and Applied Mechanics, Indian Institute of Engineering Science and Technology, Howrah, West Bengal 711103, India; Department of Mechanical Engineering, SRM Institute of Science & Technology, Kattankulathur, Kancheepuram, Chennai, Tamil Nadu 603203, India
| | - Santanu Majumder
- Department of Aerospace Engineering and Applied Mechanics, Indian Institute of Engineering Science and Technology, Shibpur, Howrah, West Bengal 711103, India
| | - Amit RoyChowdhury
- Department of Aerospace Engineering and Applied Mechanics, Indian Institute of Engineering Science and Technology, Shibpur, Howrah, West Bengal 711103, India
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16
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Lamb JN, Jain S, King SW, West RM, Pandit HG. Risk Factors for Revision of Polished Taper-Slip Cemented Stems for Periprosthetic Femoral Fracture After Primary Total Hip Replacement: A Registry-Based Cohort Study from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. J Bone Joint Surg Am 2020; 102:1600-1608. [PMID: 32604382 DOI: 10.2106/jbjs.19.01242] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total hip replacement (THR) with a cemented polished taper-slip (PTS) femoral stem has excellent long-term results but is associated with a higher postoperative periprosthetic femoral fracture (PFF) risk compared with composite beam stems. This study aimed to identify risk factors associated with PFF revision following THR with PTS stems. METHODS In a retrospective cohort study, 299,019 primary THRs using PTS stems from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) were included, with a median follow-up of 5.2 years (interquartile range [IQR], 3.1 to 8.2 years). The adjusted hazard ratio (HR) of PFF revision was estimated for each variable using multivariable Cox survival regression analysis. RESULTS Of 299,019 THR cases, 1,055 underwent revision for PFF at a median time of 3.1 years (IQR, 1.0 to 6.1 years). The mean age (and standard deviation) was 72 ± 9.7 years, 64.3% (192,365 patients) were female, and 82.6% (247,126 patients) had an American Society of Anesthesiologists (ASA) class of 1 or 2. Variables associated with increased PFF were increasing age (HR, 1.02 per year), intraoperative fracture (HR, 2.57 [95% confidence interval (CI), 1.42 to 4.66]), ovaloid (HR, 1.96 [95% CI, 1.22 to 3.16]) and round cross-sectional shapes (HR, 9.58 [95% CI, 2.29 to 40.12]), increasing stem offset (HR, 1.07 per millimeter), increasing head size (HR, 1.04 per millimeter), THR performed from 2012 to 2016 (HR, 1.45 [95% CI, 1.18 to 1.78]), cobalt-chromium stem material (HR, 6.7 [95% CI, 3.0 to 15.4]), and cobalt-chromium stems with low-viscosity cement (HR, 22.88 [95% CI, 9.90 to 52.85]). Variables associated with a decreased risk of PFF revision were female sex (HR, 0.52 [95% CI, 0.45 to 0.59]), increasing stem length (HR, 0.97 per millimeter), and a ceramic-on-polyethylene bearing (HR, 0.55 [95% CI, 0.36 to 0.85]). CONCLUSIONS Increased risk of PFF revision was associated with PTS stems that are short, have high offset, are used with large femoral heads, are made of cobalt-chromium, or have ovaloid or round cross-sectional shapes. Large increases in PFF risk were associated with cobalt-chromium stems used with low-viscosity cement. Further study is required to confirm causation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- J N Lamb
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom
| | - S Jain
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - S W King
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom
| | - R M West
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - H G Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom.,Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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17
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Johnson AJ, Desai S, Zhang C, Koh K, Zhang LQ, Costales T, O'Toole RV, Manson TT. A Calcar Collar Is Protective Against Early Torsional/Spiral Periprosthetic Femoral Fracture: A Paired Cadaveric Biomechanical Analysis. J Bone Joint Surg Am 2020; 102:1427-1433. [PMID: 32816417 DOI: 10.2106/jbjs.19.01125] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic fracture is a leading reason for readmission following total hip arthroplasty. Most of these fractures occur during the early postoperative period before bone ingrowth. Before ingrowth occurs, the femoral component can rotate relative to the femoral canal, causing a spiral fracture pattern. We sought to evaluate, in a paired cadaver model, whether the torsional load to fracture was higher in collared stems. The hypothesis was that collared stems have greater load to fracture under axial and torsional loads compared with collarless stems. METHODS Twenty-two cadaveric femora (11 matched pairs) with a mean age of 77 ± 10.2 years (range, 54 to 90 years) were harvested. Following dissection, the femora were evaluated with use of a dual x-ray absorptiometry scanner and T scores were recorded. We utilized a common stem that is available with the same intraosseous geometry with and without a collar. For each pair, 1 femur was implanted with a collared stem and the contralateral femur was implanted with a collarless stem with use of a standard broaching technique. A compressive 68-kg load was applied to simulate body weight during ambulation. A rotational displacement was then applied until fracture occurred. Peak torque prior to fracture was measured with use of a torque meter load cell and data acquisition software. RESULTS The median torque to fracture was 65.4 Nm for collared stems and 43.1 Nm for uncollared stems (p = 0.0014, Wilcoxon signed-rank test). The median T score was -1.95 (range, -4.1 to -0.15). The median difference in torque to fracture was 29.18 Nm. As expected in each case, the mode of failure was a spiral fracture around the implant. CONCLUSIONS Collared stems seemed to offer a protective effect in torsional loading in this biomechanical model comparing matched femora. CLINICAL RELEVANCE These results may translate into a protective effect against early periprosthetic Vancouver B2 femoral fractures that occur before osseous integration has occurred.
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Affiliation(s)
- Aaron J Johnson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland
| | - Shivam Desai
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland
| | - Chunyang Zhang
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland
| | - Kyung Koh
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland
| | - Li-Qun Zhang
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland.,Department of Bioengineering, University of Maryland School of Engineering, College Park, Maryland
| | - Timothy Costales
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics (A.J.J., S.D., L.-Q.Z., T.C., R.V.O., and T.T.M), and the Department of Physical Therapy and Rehabilitation Science (C.Z., K.K., and L.-Q.Z.), University of Maryland Medical System, Baltimore, Maryland
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18
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Iwase T, Morita D, Takemoto G. The effects of patient characteristics and stem alignment on distal femoral cortical hypertrophy after cemented polished tapered stem implantation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:559-567. [PMID: 31853636 DOI: 10.1007/s00590-019-02605-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 12/13/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the results of over 10 years of total hip arthroplasty (THA) practice with ExeterTM stems and the clinical relevance of distal femoral cortical hypertrophy (DFCH). METHODS We retrospectively reviewed 127 hips (120 patients) that had undergone THA with ExeterTM stems between 2004 and 2007. Kaplan-Meier survival analyses for the stem of all 127 hips were performed using different endpoints. Of 127 hips, 100 (94 patients) had complete 10-year follow-up data, including the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) as the patient-reported outcomes, and the clinical relevance of DFCH was analyzed using multivariable logistic regression analysis. RESULTS The survival of the stem with the endpoint of re-operation for loosening, > 5-mm subsidence, and re-operation for any reason were 100%, 99.1% (95% CI 97.5-100%), and 98.3% (95% CI 96.0-100%), respectively. Of 100 hips followed completely for 10 years, DFCH occurred in 20 hips (20%). The satisfaction and pain visual analog scale of JHEQ revealed high satisfaction and less pain in patients with DFCH. By multivariate logistic regression analysis, body weight > 55 kg (odds ratio: 2.88, p = 0.035) and varus stem alignment (odds ratio: 6.56, p = 0.003) were found to be predictors for DFCH. CONCLUSIONS The incidence of DFCH with the ExeterTM stem was 20%. A body weight > 55 kg and varus stem alignment are predictors for future DFCH. DFCH with the ExeterTM stem indicates a good outcome with less hip pain.
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Affiliation(s)
- Toshiki Iwase
- Department of Orthopedic Surgery, Hamamatsu Medical Center, 328 Tomitsuka-cho, Naka-ku, Hamamatsu, Shizuoka, 432-8580, Japan.
| | - Daigo Morita
- Department of Orthopedic Surgery, Hamamatsu Medical Center, 328 Tomitsuka-cho, Naka-ku, Hamamatsu, Shizuoka, 432-8580, Japan
| | - Genta Takemoto
- Department of Orthopedic Surgery, Hamamatsu Medical Center, 328 Tomitsuka-cho, Naka-ku, Hamamatsu, Shizuoka, 432-8580, Japan
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19
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Mohammed J, Mukka S, Hedbeck CJ, Chammout G, Gordon M, Sköldenberg O. Reduced periprosthetic fracture rate when changing from a tapered polished stem to an anatomical stem for cemented hip arthroplasty: an observational prospective cohort study with a follow-up of 2 years. Acta Orthop 2019; 90:427-432. [PMID: 31154885 PMCID: PMC6746294 DOI: 10.1080/17453674.2019.1624339] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Straight collarless polished tapered stems have been linked to an increased risk for periprosthetic femur fractures in comparison with anatomically shaped stems, especially in elderly patients. Therefore, we evaluated the effect of an orthopedic department's full transition from the use of a cemented collarless, polished, tapered stem to a cemented anatomic stem on the cumulative incidence of postoperative periprosthetic fracture (PPF). Patients and methods - This prospective single-center cohort study comprises a consecutive series of 1,077 patients who underwent a cemented hip arthroplasty using either a collarless polished tapered stem (PTS group, n = 543) or an anatomic stem (AS group, n = 534). We assessed the incidence of PPF 2 years postoperatively and used a Cox regression model adjusted for age, sex, ASA class, cognitive impairment, BMI, diagnosis, and surgical approach for outcome analysis. Results - Mean age at primary surgery was 82 years (49-102), 73% of the patients were female, and 75% underwent surgery for a femoral neck fracture. The PPF rate was lowered from 3.3% (n = 18) in the PTS group to 0.4% (n = 2) in the AS group. The overall complication rate was also lowered from 8.8% in the PTS group to 4.5% in the AS group. In the regression model only cognitive dysfunction (HR 3.8, 95% CI 1.4-10) and the type of stem (PTS vs AS, HR 0.1, CI 0.0-0.5) were correlated with outcome. Interpretation - For elderly patients with poor bone quality use of cemented anatomic stems leads to a substantial reduction in periprosthetic fracture rate without increasing other complications.
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Affiliation(s)
- Jabbar Mohammed
- Department of Surgical and Perioperative Sciences, Umeå University; ,Correspondence:
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences, Umeå University;
| | - Carl-Johan Hedbeck
- Department of Clinical Sciences, Division of Orthopedics, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Ghazi Chammout
- Department of Clinical Sciences, Division of Orthopedics, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Max Gordon
- Department of Clinical Sciences, Division of Orthopedics, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Olof Sköldenberg
- Department of Clinical Sciences, Division of Orthopedics, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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20
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Klasan A, Bäumlein M, Bliemel C, Putnis SE, Neri T, Schofer MD, Heyse TJ. Cementing of the hip arthroplasty stem increases load-to-failure force: a cadaveric study. Acta Orthop 2019; 90:445-449. [PMID: 31282247 PMCID: PMC6746255 DOI: 10.1080/17453674.2019.1634331] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - To date, there is not a single clinical or mechanical study directly comparing a cemented and a cementless version of the same stem. We investigated the load-to-failure force of a cementless and a cemented version of a double tapered stem. Material and methods - 10 femurs from 5 human cadaveric specimens, mean age 74 years (68-79) were extracted. Bone mineral density (BMD) was measured using peripheral quantitative computed tomography. None of the specimens had a compromised quality (average T value 0.0, -1.0 to 1.4). Each specimen from a pair randomly received a cemented or a cementless version of the same stem. A material testing machine was used for lateral load-to-failure test of up to a maximal load of 5.0 kN. Results - Average load-to-failure of the cemented stem was 2.8 kN (2.3-3.2) and 2.2 kN (1.8-2.8) for the cementless stem (p = 0.002). The cemented version of the stem sustained a higher load than its cementless counterpart in all cases. Failure force was not statistically significantly correlated to BMD (p = 0.07). Interpretation - Implanting a cemented version of the stem increases the load-to-failure force by 25%.
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Affiliation(s)
- Antonio Klasan
- University Hospital Marburg, Center for Orthopedics and Traumatology, Marburg, Germany; ,Correspondence:
| | - Martin Bäumlein
- University Hospital Marburg, Center for Orthopedics and Traumatology, Marburg, Germany;
| | - Christopher Bliemel
- University Hospital Marburg, Center for Orthopedics and Traumatology, Marburg, Germany;
| | | | - Thomas Neri
- University Hospital St. Etienne, Department of Orthopaedic Surgery, Saint-Priest-en-Jatez, France;
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21
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Irie T, Takahashi D, Asano T, Shimizu T, Arai R, Terkawi AM, Ito YM, Iwasaki N. Effects of femoral bone defect morphology on initial polished tapered stem stability in massive defect model: a biomechanical study. BMC Musculoskelet Disord 2019; 20:355. [PMID: 31370807 PMCID: PMC6670119 DOI: 10.1186/s12891-019-2716-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/11/2019] [Indexed: 11/13/2022] Open
Abstract
Background Good outcomes have been reported in revision total hip replacement with massive segmental defects using impaction bone grafting with circumferential metal meshes. However, the morphology of defects that require a mesh is poorly defined. The purpose of this study was to evaluate the effects of a variety of segmental defects on load transmission to the proximal femur under both axial and rotational loads. Methods Initial stability of the Exeter stem was investigated in a composite bone model using three medial bone defect morphologies: Long (length 5 cm × width 2 cm), Short (2.5 cm × 2 cm), Square (3.2 cm × 3.2 cm), Square with mesh (3.2 cm × 3.2 cm defect covered with metal mesh), and with no defect as control. Specimens (5 per group) were axially loaded and internally rotated up to 20° or to failure. Strain distributions of the femora were measured using a strain gauge. Results All Square group specimens failed while rotation was increasing. In the other four groups, failure was not observed in any specimens. Mean torsional stiffness in the Long (4.4 ± 0.3 Nm/deg.) and Square groups (4.3 ± 0.3 Nm/deg.) was significantly smaller than in the Control group (4.8 ± 0.3 Nm/deg.). In the medio-cranial region, the magnitude of the maximum principal strain in the Square group (1176.4 ± 100.9) was significantly the largest (Control, 373.2 ± 129.5, p < 0.001; Long, 883.7 ± 153.3, p = 0.027; Short, 434.5 ± 196.8, p < 0.001; Square with mesh, 256.9 ± 100.8, p < 0.001). Torsional stiffness, and both maximum and minimum principal strains in the Short group showed no difference compared to the Control group in any region. Conclusions Bone defect morphology greatly affected initial stem stability and load transmission. If defect morphology is not wide and the distal end is above the lower end of the lesser trochanter, it may be acceptable to fill the bone defect region with bone cement. However, this procedure is not acceptable for defects extending distally below the lower end of the lesser trochanter or defects 3 cm or more in width.
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Affiliation(s)
- Tohru Irie
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Daisuke Takahashi
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tsuyoshi Asano
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tomohiro Shimizu
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Ryuta Arai
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Alaa Muhammad Terkawi
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
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Lamb JN, Baetz J, Messer-Hannemann P, Adekanmbi I, van Duren BH, Redmond A, West RM, Morlock MM, Pandit HG. A calcar collar is protective against early periprosthetic femoral fracture around cementless femoral components in primary total hip arthroplasty: a registry study with biomechanical validation. Bone Joint J 2019; 101-B:779-786. [PMID: 31256663 DOI: 10.1302/0301-620x.101b7.bjj-2018-1422.r1] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS The aim of this study was to estimate the 90-day risk of revision for periprosthetic femoral fracture associated with design features of cementless femoral stems, and to investigate the effect of a collar on this risk using a biomechanical in vitro model. MATERIALS AND METHODS A total of 337 647 primary total hip arthroplasties (THAs) from the United Kingdom National Joint Registry (NJR) were included in a multivariable survival and regression analysis to identify the adjusted hazard of revision for periprosthetic fracture following primary THA using a cementless stem. The effect of a collar in cementless THA on this risk was evaluated in an in vitro model using paired fresh frozen cadaveric femora. RESULTS The prevalence of early revision for periprosthetic fracture was 0.34% (1180/337 647) and 44.0% (520/1180) occurred within 90 days of surgery. Implant risk factors included: collarless stem, non-grit-blasted finish, and triple-tapered design. In the in vitro model, a medial calcar collar consistently improved the stability and resistance to fracture. CONCLUSION Analysis of features of stem design in registry data is a useful method of identifying implant characteristics that affect the risk of early periprosthetic fracture around a cementless femoral stem. A collar on the calcar reduced the risk of an early periprosthetic fracture and this was confirmed by biomechanical testing. This approach may be useful in the analysis of other uncommon modes of failure after THA. Cite this article: Bone Joint J 2019;101-B:779-786.
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Affiliation(s)
- J N Lamb
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - J Baetz
- Department of Biomechanics, Hamburg University of Technology, Hamburg, Germany
| | - P Messer-Hannemann
- Department of Biomechanics, Hamburg University of Technology, Hamburg, Germany
| | - I Adekanmbi
- DePuy International, Johnson and Johnson, Leeds, UK
| | - B H van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - A Redmond
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - R M West
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - M M Morlock
- Department of Biomechanics, Hamburg University of Technology, Hamburg, Germany
| | - H G Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
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Woodbridge AB, Hubble MJ, Whitehouse SL, Wilson MJ, Howell JR, Timperley AJ. The Exeter Short Revision Stem for Cement-in-Cement Femoral Revision: A Five to Twelve Year Review. J Arthroplasty 2019; 34:S297-S301. [PMID: 31000404 DOI: 10.1016/j.arth.2019.03.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Cement-in-cement femoral revision is a proven technique in revision total hip arthroplasty, with excellent results reported using standard-sized Exeter stems. The Exeter 44/00/125 short revision stem was introduced in 2004 to facilitate cement-in-cement revision. The stem is 25-mm shorter and has a slimmer body than standard stems to facilitate adjustment of depth of insertion and stem version. It is not known if this change in stem size affects its long-term performance. We therefore reviewed the outcome of all Exeter short revision stems used for cement-in-cement revision in our unit, with a minimum of 5 years of follow-up. METHOD One hundred sixty-six cases were performed between 2004 and 2010. Mean follow-up of surviving patients was 8.1 years (range 5.0-11.7). The fate of all 166 hips were known and included in the survival analysis. RESULTS Median clinical scores improved significantly. Sixteen hips required re-revision (infection 6, loose cup 3, periprosthetic fracture 3, instability 2, stem fracture with chronic infection 1, and pain 1). Kaplan-Meier survival analysis at 10 years revealed 100% survival for aseptic stem loosening, 96.8% survival for stem failure, and 88.9% survival for all causes. CONCLUSION The Exeter short revision stem performed as well as standard length stems for cement-in-cement revision in this the largest and longest review of their use. Larger registry-based studies may provide additional information on the performance of this stem.
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Affiliation(s)
- Adam B Woodbridge
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Matthew J Hubble
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Sarah L Whitehouse
- Department of Orthopaedic Research, Queensland University of Technology, Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Matthew J Wilson
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Jonathan R Howell
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Andrew J Timperley
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
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Stevens J, Clement N, Nasserallah M, Millar M, Joseph S. Femoral cortical thickness influences the pattern of proximal femoral periprosthetic fractures with a cemented stem. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:659-665. [DOI: 10.1007/s00590-018-2141-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
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Carli AV, Negus JJ, Haddad FS. Periprosthetic femoral fractures and trying to avoid them: what is the contribution of femoral component design to the increased risk of periprosthetic femoral fracture? Bone Joint J 2017; 99-B:50-59. [PMID: 28042119 DOI: 10.1302/0301-620x.99b1.bjj-2016-0220.r1] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/27/2016] [Indexed: 11/05/2022]
Abstract
AIMS Periprosthetic femoral fractures (PFF) following total hip arthroplasty (THA) are devastating complications that are associated with functional limitations and increased overall mortality. Although cementless implants have been associated with an increased risk of PFF, the precise contribution of implant geometry and design on the risk of both intra-operative and post-operative PFF remains poorly investigated. A systematic review was performed to aggregate all of the PFF literature with specific attention to the femoral implant used. PATIENTS AND METHODS A systematic search strategy of several journal databases and recent proceedings from the American Academy of Orthopaedic Surgeons was performed. Clinical articles were included for analysis if sufficient implant description was provided. All articles were reviewed by two reviewers. A review of fundamental investigations of implant load-to-failure was performed, with the intent of identifying similar conclusions from the clinical and fundamental literature. RESULTS In total 596 articles were initially identified, with 34 being eligible for analysis. Aggregate analysis of 1691 PFFs in 342 719 primary THAs revealed a significantly higher number of PFFs with cementless femoral implants (p < 0.001). Single-wedge and double-wedge (fit-and-fill) femoral implants were associated with a threefold increase in PFF rates (p < 0.001) compared with anatomical, fully coated and tapered/rounded stems. Within cemented stems, loaded-taper (Exeter) stems were associated with more PFFs than composite-beam (Charnley) stems (p = 0.004). Review of the fundamental literature revealed very few studies comparing cementless component designs. CONCLUSION Very few studies within the PFF literature provide detailed implant information. Cementless implants, specifically those of single-wedge and double-wedge, have the highest PFF rates in the literature, with most investigations recommending against their use in older patients with osteoporotic bone. This review illustrates the need for registries and future PFF studies to record implant name and information for future analysis. Furthermore, future biomechanical investigations comparing modern implants are needed to clarify the precise contribution of implant design to PFF risk. Cite this article: Bone Joint J 2017;99-B(1 Supple A):50-9.
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Affiliation(s)
- A V Carli
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - J J Negus
- University College London Hospitals, 235 Euston Road, London, NW1 2BU and NIHR University College London Hospitals Biomedical Research Centre, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London, NW1 2BU and NIHR University College London Hospitals Biomedical Research Centre, UK
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Desy NM, Johnson JD, Sierra RJ. Satisfactory Results of the Exeter Revision Femoral Stem Used for Primary Total Hip Arthroplasty. J Arthroplasty 2017; 32:494-498. [PMID: 27600303 DOI: 10.1016/j.arth.2016.07.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Exeter cemented femoral stem has demonstrated excellent clinical and radiographic outcomes as well as long-term survivorship free from aseptic loosening. A shorter revision stem (125 mm) with a 44 offset became available for the purpose of cement-in-cement revision situations. In certain cases, this shorter revision stem may be used for various primary total hip arthroplasties (THAs) where the standard length stem would require distally reaming the femoral canal. We sought to report on the early to midterm results of this specific stem when used for primary THA regarding (1) clinical and radiographic outcomes, (2) complications, and (3) survivorship. METHODS Twenty-nine patients (33 hips) underwent a hybrid THA using the smaller revision Exeter cemented femoral stem. Twenty-five patients (28 hips) had at least 2 years of follow-up and were assessed for clinical and radiographic outcomes. All 33 hips were included in the analysis of complications and survivorship. The Kaplan-Meier survivorship was performed using revision for all causes and for aseptic loosening as the end points. RESULTS The average clinical follow-up was 4 years (range, 2-7). Harris Hip Scores improved from a mean preoperative value of 56 (range, 23-96) to 90 (range, 51-100) at the latest follow-up. All patients demonstrated superior cement mantles with no signs of loosening. One patient suffered a B2 periprosthetic fracture and 1 patient experienced 2 episodes of instability. The 5-year Kaplan-Meier survivorship was 96.7% for all causes of revision and was 100% using aseptic loosening as the end point. CONCLUSION The shorter Exeter revision cemented femoral stem has favorable early to midterm clinical and radiographic outcomes when used for primary THA with a low complication rate and is a viable option in patients with narrow femoral canals where uncemented stem fixation is not desired.
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Affiliation(s)
- Nicholas M Desy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joshua D Johnson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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27
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Mukka S, Mellner C, Knutsson B, Sayed-Noor A, Sköldenberg O. Substantially higher prevalence of postoperative peri-prosthetic fractures in octogenarians with hip fractures operated with a cemented, polished tapered stem rather than an anatomic stem. Acta Orthop 2016; 87:257-61. [PMID: 27045318 PMCID: PMC4900095 DOI: 10.3109/17453674.2016.1162898] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Recent studies have demonstrated a high incidence of postoperative periprosthetic femoral fracture (PPF) in elderly patients treated with 2 commonly used cemented, polished tapered stems. We compared the prevalence and incidence rate of PPF in a consecutive cohort of octagenerians with femoral neck fractures (FNFs) treated with either a collarless, polished tapered (CPT) stem or an anatomic matte stem (Lubinus SP2). Patients and methods - In a multicenter, prospective cohort study, we included 979 hips in patients aged 80 years and above (72% females, median age 86 (80-102) years) with a femoral neck fracture as indication for surgery. 69% of the patients were classified as ASA class 3 or 4. Hip-related complications and repeat surgery were assessed at a median follow-up of 20 (0-24) months postoperatively. Results - 22 hips (2.2%) sustained a PPF at a median of 7 (0-22) months postoperatively; 14 (64%) were Vancouver B2 fractures. 7 of the 22 surgically treated fractures required revision surgery, mainly due to deep infection. The cumulative incidence of PPFs was 3.8% in the CPT group, as compared with 0.2% in the SP2 group (p < 0.001). The risk ratio (RR) was 16 (95% CI: 2-120) using the SP2 group as denominator. Interpretation - The CPT stem was associated with a higher risk of PPF than the SP2 stem. We suggest that the tapered CPT stem should not be used for the treatment of femoral neck fractures in patients over 80 years.
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Affiliation(s)
- Sebastian Mukka
- Department of Orthopedics, Sundsvall Hospital, Sundsvall, and Department of Surgical and Perioperative Sciences, Umeå University, Umeå;;,Correspondence:
| | - Carl Mellner
- Department of Orthopedics, Sundsvall Hospital, Sundsvall, and Department of Surgical and Perioperative Sciences, Umeå University, Umeå;;
| | - Björn Knutsson
- Department of Orthopedics, Sundsvall Hospital, Sundsvall, and Department of Surgical and Perioperative Sciences, Umeå University, Umeå;;,Department of Surgical Sciences, Section of Orthopedics, Uppsala University, Uppsala;
| | - Arkan Sayed-Noor
- Department of Orthopedics, Sundsvall Hospital, Sundsvall, and Department of Surgical and Perioperative Sciences, Umeå University, Umeå;;
| | - Olof Sköldenberg
- Department of Orthopedics, Danderyd Hospital and Karolinska Institutet, Stockholm, and Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
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Gordon K, Winkler M, Hofstädter T, Dorn U, Augat P. Managing Vancouver B1 fractures by cerclage system compared to locking plate fixation - a biomechanical study. Injury 2016; 47 Suppl 2:S51-7. [PMID: 27338228 DOI: 10.1016/s0020-1383(16)47009-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
With increasing life expectancy and number of total hip arthroplasties (THA), the need for revision surgery is increasing too. The aim of this study was to evaluate the optimal fracture treatment for a clinically characteristic Vancouver B1 fracture. We hypothesized that locking plate fixation has biomechanical advantages over fixation with a simple cerclage system. Additionally, we hypothesized that removal of the primary short stem and revision with a long stem would show biomechanical benefit. The biomechanical testing was performed with a static and a dynamic loading protocol on twenty 4th Generation sawbones. These were divided into four different groups (n = 5 each). In group 1, the primary uncemented short stem remained and the fracture was stabilized with a locking plate. In group 2, the primary stem remained and the fracture was stabilized with a cerclage stabilization system containing two stabilizers and four cerclages. In group 3, the primary stem was replaced by an uncemented long revision stem and the fracture was fixed with a locking plate. In group 4, the short stem was replaced by a long revision stem and the fracture was fixed with the cerclage system. Static testing revealed that the revision of the short stem with the long stem caused a 2-fold (p < 0.001, ANOVA) increase of axial stiffness. In dynamic testing, the number of cycles to failure was 4 times (p < 0.001, ANOVA) higher with the long revision stem. Compared to locked plating cerclage wiring demonstrated a 26% more cycles to failure (p = 0.031, ANOVA). The load to failure was 91% larger (p < 0.001, ANOVA) with the long revision stem and 11% smaller with locked plating (p < 0.001, ANOVA). In conclusion, the present biomechanical study indicates that periprosthetic Vancouver B1 fractures can be sufficiently fixed by simple cerclage systems. Revision with a long replacement stem provides a superior mechanical stability regardless of type of osteosynthesis fixation and is therefore a viable method in Vancouver B1 cases. A disadvantage of the cerclage system compared to plating is that an increased subsidence of the short stem was observed.
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Affiliation(s)
- Katharina Gordon
- Department of Orthopedic Surgery, Salzburg General Hospital, Paracelsus Medical University, Müllner Hauptstr. 48, 5020Salzburg, Austria.
| | - Martin Winkler
- Institute of Biomechanics, Trauma Center Murnau, Prof. Küntscher-Str. 8, 82418Murnau, Germany.
| | - Thomas Hofstädter
- Department of Orthopedic Surgery, Salzburg General Hospital, Paracelsus Medical University, Müllner Hauptstr. 48, 5020Salzburg, Austria
| | - Ulrich Dorn
- Department of Orthopedic Surgery, Salzburg General Hospital, Paracelsus Medical University, Müllner Hauptstr. 48, 5020Salzburg, Austria
| | - Peter Augat
- Institute of Biomechanics, Trauma Center Murnau, Prof. Küntscher-Str. 8, 82418Murnau, Germany; Institute of Biomechanics, Paracelsus Medical University Salzburg, Strubergasse 21, 5020Salzburg, Austria
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Jakubowitz E, Seeger JB. Periprosthetic fractures: concepts of biomechanical in vitro investigations. INTERNATIONAL ORTHOPAEDICS 2015; 39:1971-9. [PMID: 26294001 DOI: 10.1007/s00264-015-2954-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Experimental in vitro studies investigating periprosthetic fractures after joint replacement are used increasingly. The purpose of this review was to deliver a condensed survey of studies in order to provide researchers with an overview of relevant scientific results and their clinical relevance. METHODS A literature search was conducted to obtain all available papers dealing with periprosthetic fractures, with particular attention being paid to articles with an experimental research design. Study goals, scientific methods and results, their interpretation and clinical relevance were assessed and compared. The main focus was on comparability with clinical fracture patterns and physiological joint loads. RESULTS Excluding duplicates, 24 studies with regard to artificial hip, knee and shoulder joints were found dating back to August 2000. Almost all studies were performed quasi-statically and without consideration of muscle forces and thus reflect selected loading conditions and no dynamic situation during activities of daily living (ADL). Various experimental protocols were used, differing in the choice of experimental material, implant and fixation system and load application. CONCLUSIONS In vitro studies regarding periprosthetic fracture research allow controlling for disturbances, such as clinically occurring risk factors like reduced bone mineral density (BMD) or greater patient age. Notwithstanding, due to methodological differences, comparisons between studies were possible to a limited degree only. For this reason, and because of quasi-static loading typically applied, results can only be partially applied to clinical practice.
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Affiliation(s)
- Eike Jakubowitz
- Laboratory for Biomechanics and Biomaterials (LBB), Department of Orthopaedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30628, Hannover, Germany.
| | - Jörn Bengt Seeger
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM), Klinikstrasse 33, 35392, Giessen, Germany
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Brodén C, Mukka S, Muren O, Eisler T, Boden H, Stark A, Sköldenberg O. High risk of early periprosthetic fractures after primary hip arthroplasty in elderly patients using a cemented, tapered, polished stem. Acta Orthop 2015; 86:169-74. [PMID: 25280133 PMCID: PMC4404766 DOI: 10.3109/17453674.2014.971388] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Postoperative periprosthetic femoral fracture (PPF) after hip arthroplasty is associated with considerable morbidity and mortality. We assessed the incidence and characteristics of periprosthetic fractures in a consecutive cohort of elderly patients treated with a cemented, collarless, polished and tapered femoral stem (CPT). PATIENTS AND METHODS In this single-center prospective cohort study, we included 1,403 hips in 1,357 patients (mean age 82 (range 52-102) years, 72% women) with primary osteoarthritis (OA) or a femoral neck fracture (FNF) as indication for surgery (367 hips and 1,036 hips, respectively). 64% of patients were ASA class 3 or 4. Hip-related complications and need for repeat surgery were assessed at a mean follow-up time of 4 (1-7) years. A Cox regression analysis was used to evaluate risk factors associated with PPF. RESULTS 47 hips (3.3%) sustained a periprosthetic fracture at median 7 (2-79) months postoperatively; 41 were comminute Vancouver B2 or complex C-type fractures. The fracture rate was 3.8% for FNF patients and 2.2% for OA patients (hazard ratio (HR) = 4; 95% CI: 1.3-12). Patients > 80 years of age also had a higher risk of fracture (HR = 2; 95% CI: 1.1-4.5). INTERPRETATION We found a high incidence of early PPF associated with the CPT stem in this old and frail patient group. A possible explanation may be that the polished tapered stem acts as a wedge, splitting the femur after a direct hip contusion. Our results should be confirmed in larger, registry-based studies, but we advise caution when using this stem for this particular patient group.
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Affiliation(s)
- Cyrus Brodén
- Department of Orthopedics at Danderyd Hospital and Department of Clinical Sciences at Danderyd Hospital (KIDS), Karolinska Institutet, Stockholm
| | - Sebastian Mukka
- Department of Orthopedics, Sundsvall Hospital, Sundsvall, and Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Olle Muren
- Department of Orthopedics at Danderyd Hospital and Department of Clinical Sciences at Danderyd Hospital (KIDS), Karolinska Institutet, Stockholm
| | - Thomas Eisler
- Department of Orthopedics at Danderyd Hospital and Department of Clinical Sciences at Danderyd Hospital (KIDS), Karolinska Institutet, Stockholm
| | - Henrik Boden
- Department of Orthopedics at Danderyd Hospital and Department of Clinical Sciences at Danderyd Hospital (KIDS), Karolinska Institutet, Stockholm
| | - André Stark
- Department of Orthopedics at Danderyd Hospital and Department of Clinical Sciences at Danderyd Hospital (KIDS), Karolinska Institutet, Stockholm
| | - Olof Sköldenberg
- Department of Orthopedics at Danderyd Hospital and Department of Clinical Sciences at Danderyd Hospital (KIDS), Karolinska Institutet, Stockholm
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Ginsel BL, Morishima T, Wilson LJ, Whitehouse SL, Crawford RW. Can larger-bodied cemented femoral components reduce periprosthetic fractures? A biomechanical study. Arch Orthop Trauma Surg 2015; 135:517-22. [PMID: 25724411 DOI: 10.1007/s00402-015-2172-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The risk for late periprosthetic femoral fractures is higher in patients treated for a neck of femur fracture compared to osteoarthritis. It has been hypothesised that osteopaenia and consequent decreased stiffness of the proximal femur are responsible for this. We investigated whether a femoral component with a bigger body would increase the torque to failure in a biaxially loaded composite Sawbone model. MATERIALS AND METHODS A biomechanical bone analogue was used. Two different body sizes (Exeter 44-1 versus 44-4) of a polished tapered cemented femoral stem were implanted by an experienced surgeon in seven bone analogues each and internally rotated at 40°/s until failure. Torque to fracture and fracture energy were measured using a biaxial materials testing device (Instron 8874, MI, USA). The data were non-parametric and therefore tested with the Mann-Whitney U test. RESULTS The median torque to fracture was 156.7 Nm (IQR 19.7) for the 44-1 stem and 237.1 Nm (IQR 52.9) for the 44-4 stem (p = 0.001). The median fracture energy was 8.5 J (IQR 7.3) for the 44-1 stem and 19.5 J (IQR 8.8) for the 44-4 stem (p = 0.014). CONCLUSION The use of large body polished tapered cemented stems for neck of femur fractures increases the torque to failure in a biomechanical model and therefore is likely to reduce late periprosthetic fracture risk in this vulnerable cohort.
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Affiliation(s)
- Bastiaan L Ginsel
- Institute of Health and Biomedical Innovation, Queensland University of Technology, The Prince Charles Hospital, Chermside, Brisbane, QLD, 4032, Australia
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Abstract
Various short hip stems have been introduced with differing implant concepts of femoral fixation and implant length. There is a lack of proper classification for short hip stems, with a clear and accepted definition for implant length and extent of bone preservation in the metaphyseal and diaphyseal femur. This study analyzed the length of short hip stems. Stems were divided into collum, partial collum, and trochanter-sparing implants. An additional category was added, trochanter harming, which was defined as interruption of the circumferential integrity of the femoral neck. For all of the femoral components described, the designs were compared, excluding stems with insufficient clinical data. The 15 finally selected stems were classified as collum (1 stem), partial collum (7 stems), trochanter sparing (4 stems), and trochanter harming (3 stems). Mid-term results (>5 years of follow-up) were available for only 3 designs in the partial collum group. Taking into account the results of short-term studies (<5 years of follow-up), the femoral revision rate per 100 observed component years was <1 for most total hip arthroplasties. However, the studies varied greatly regarding level of significance, and short hip stems without published results are available commercially. Short hip stems cannot be circumscribed by a simple length limit. For some designs, clinical data collected from large patient cohorts showed a survivorship comparable to traditional stems. In cases that must be revised, this often can be performed with a conventional primary stem, fulfilling the promise to preserve bone for potential future revisions in younger patients.
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33
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Abstract
Many different lengths of stem are available for use in primary total hip replacement, and the morphology of the proximal femur varies greatly. The more recently developed shortened stems provide a distribution of stress which closely mimics that of the native femur. Shortening the femoral component potentially comes at the cost of decreased initial stability. Clinical studies on the performance of shortened cemented and cementless stems are promising, although long-term follow-up studies are lacking. We provide an overview of the current literature on the anatomical features of the proximal femur and the biomechanical aspects and clinical outcomes associated with the length of the femoral component in primary hip replacement, and suggest a classification system for the length of femoral stems.
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Affiliation(s)
- H Feyen
- Melbourne Orthopaedic Group, 33 the Avenue, Windsor, 3181, Victoria, Australia
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