Fractured Femoral Stems in Primary and Revision Hip Arthroplasties Revisited: Wrightington Experience

Risk factors for femoral stem fracture following total hip arthroplasty: a systematic review and meta analysis

BACKGROUND

Femoral stem fracture following total hip arthroplasty (THA) is an infrequent but nevertheless devastating complication, with an increasing worldwide prevalence as demand for primary THA continues to increase. The aim of this study was to perform a systematic review and meta-analysis of risk factors for femoral stem fracture to help identify at risk patients.

METHODS

A systematic search was conducted on EMBASE, MEDLINE and AMED to identify relevant studies. Data regarding study design, source, population, intervention, and outcomes was collated. Data extraction was performed on a custom form generated using Cochrane recommended methodology and analysis of risk factors performed including odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

A total of 15 studies reporting a total of 402 stem fractures in 49 723 THAs were identified. The median time from index procedure to stem fracture was 68 months (IQR 42.5-118) whilst mean age at index surgery was 61.8 years (SD 6.9). Male gender (OR = 3.27, 95% CI = 2.59-4.13, p < 0.001), patient weight above 80 kg (OR = 3.55, 95% CI = 2.88-4.37, p < 0.001), age under 63 years (OR = 1.22, 95% CI = 1.01-1.49, p < 0.001), varus stem alignment (OR = 5.77, 95% CI = 3.83-8.7, p < 0.001), use of modular implants (OR = 1.95, 95% CI = 1.56-2.44, p < 0.01) and undergoing revision arthroplasty (OR = 3.33, 95% CI = 2.70-4.1, p < 0.001) were significant risk factors for prosthetic stem fracture. A risk window of 15 years post-surgery was identified.

CONCLUSIONS

This review concludes that patient weight, younger age, male sex, varus stem alignment, revision arthroplasty and use of modular stems are significant risk factors for femoral stem fracture. Modifying these risk factors where possible may help reduce incidence of femoral stem fracture in at risk patients.

Recurrent implant fractures in total hip arthroplasty: a yes-you-yan case report

This case report describes a single patient with recurrent implant fractures of his left total hip replacement. According to our knowledge this is the first patient in literature with recurrent implant fractures. This is a rare phenomenon as reason for revision. Risk factors for implant failure of total hip replacement include a lack of proximal support, a distally well fixed stem with proximal debonding, malalignment of the stem and raised BMI.

Use of a Trephine to Extract a Fractured Corail Femoral Stem During Revision Total Hip Arthroplasty: Tips From Our Case Report

Despite the significant advancements in the field of total hip arthroplasty (THA) and prosthesis designs, fracture of the modular femoral stem after THA can occur rarely and needs attention. Orthopaedic surgeons face a daunting task when it comes to the removal of a broken stem. The use of a trephine reamer has been evaluated for extracting the distal femoral stem, and this case report tries to address some key tips for the same. A 67-year-old obese male, without any major medical comorbidities, presented to the Royal Lancaster Infirmary orthopaedic outpatient department with a complaint of acute-on-chronic right anterior thigh pain that worsened over a few weeks. He had a history of bilateral staged uncemented THA done around 12 years ago. The plain radiological images confirmed the presence of a fracture of the Corail femoral stem. A posterior approach was used to dislocate the hip and the distal broken part of the stem was removed using trephines. Reamers were used and care was taken to prevent thermal necrosis by using intermittent saline lavage. After the removal of the fractured femoral stem, a cemented femoral revision THA was performed, which was uneventful. The patient walked without any aid or thigh pain postoperatively during his last follow-up. Using trephines to remove broken femoral stems is an effective and safe method. Intraoperative measures can help in avoiding heat necrosis while using a trephine reamer for extracting the fractured femoral stem. Regular follow-up and counselling are important after THA, to avoid a delayed diagnosis of non-traumatic femoral stem fractures.

Imaging of total hip arthroplasty: Part I – Implant design, imaging techniques, and imaging of component wear and fracture

Despite being one of the most reliable procedures in orthopedic surgery, complications can occur after total hip arthroplasty, and radiology plays an essential role in their evaluation. This article will review the various types of hip arthroplasty and their normal appearances on imaging, followed by mechanisms and imaging appearances of component wear and fracture.

A New Type of Periprosthetic Fracture: Is It the Time to Update the Unified Classification System?

INTRODUCTION

Increased number of primary and revision arthroplasties performed globally has led to a surge in the numbers of periprosthetic fractures. The Unified Classification System (UCS) advocated a rational approach towards the classification of periprosthetic fractures. We present here an update to the UCS with addition of new fracture pattern encountered in orthopedic practice.

METHODS

A retrospective study was conducted to review the service arthroplasty register for the cases with unique fracture pattern where the periprosthetic fracture around total hip arthroplasty was also associated with fracture of the prosthetic component. The details were retrieved from the medical record and the patients were called for a review. The radiological assessment was done with X-rays and clinical assessment with Harris Hip Scores at the latest follow-up.

RESULTS

Between 2012 and 2019, 11 patients (7 males and 4 females) were operated for peri-prosthetic fracture with a unique pattern where the fracture of femur was associated with fracture of the femoral stem as well. The mean age of the patient at the time of fracture was 56.8 years (range 42-71 years). All patients were managed with revision hip surgery. One patient died due to malignancy after 7 years of revision surgery. All the surviving patients are doing well with a mean Harris Hip Score of 86.8 at the latest follow-up of 2-9 years (mean 5.0 years).

CONCLUSION

With emergence of this new fracture pattern, it is recognition as a separate entity would help in better understanding and augmentation of the existing classification system of periprosthetic fractures.

Analysis of the Exeter V40 femoral stem prosthesis fracture : systematic review and single centre case series

Aims

The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

Methods

A systematic literature search was performed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. In parallel, we performed a retrospective single centre study of Exeter V40 femoral stem prosthetic fractures between April 2003 and June 2020.

Results

There are 25 reported cases of such prosthetic fractures confined to small case series and case reports within the literature. We report an additional 19 cases to the literature (mean age 66.3 years (SD 11.7); 12 (63%) females; BMI 32.9 kg/m² (SD 5.9)). The mean time from index procedure to fracture was 7.8 years (SD 3.6; 2.5 to 16.3). Exeter V40 stem fracture incidence was 0.15% and 1.21% for primary and revision arthroplasty, respectively. Incidence was significantly higher in revision arthroplasty (p < 0.001) and 125 mm length stems compared to ≥ 150 mm length stems (1.25% vs 0.13%, respectively; p < 0.001). When comparing different stem length cohorts, 125 mm short-stems were associated with stem-body fractures (92% vs 29%; p = 0.0095), earlier time to fracture (6.2 years vs 11.0 years; p = 0.0018), younger patient age at time of fracture (62.7 years vs 72.6 years; p = 0.037), and female sex (75% vs 43%; p = 0.326).

Conclusion

This complication remains rare, although we report a significantly higher incidence at up to 17 years follow-up than in the literature. Short 125 mm length Exeter V40 stems undoubtedly have a role in restoring anatomy and biomechanics in smaller femoral geometries, although the surgeon has to appreciate the higher risk of stem fracture and the associated predisposing factors which may necessitate particular attention to surgical technique and planning.

Cite this article: Bone Jt Open 2021;2(6):443–456.

Femoral stem fractures after primary and revision hip replacements: A single-center experience

Objectives

This study aims to present our experience in the management of fractured femoral stems after primary and revision hip replacements by evaluating the clinical and radiographic characteristics and determining the effectiveness of the extraction methods.

Patients and methods

A total of 15 patients (5 males, 10 females; mean age 65.9 years; range, 49 to 87 years) who underwent revision hip replacement due to a fractured femoral stem between January 2005 and December 2019 were included in this retrospective study. The mechanisms and risk factors for failure as well as methods applied to extract fractured stem were analyzed through clinical and radiographic data.

Results

Nine patients had fractured cemented femoral stems, while six patients had fractured fully porous coated cementless revision stems. Lack of proximal buttress in distally fixed femoral stems was detected in 11 patients and identified as the predominant mechanism resulting in fracture. The proximal extraction method with conventional revision instrumentation, the cortical window technique, and extended trochanteric osteotomy (ETO) were used in three, seven, and five cases, respectively.

Conclusion

Our results demonstrated that the lack of proximal buttress is the most common reason for femoral stem fracture. Moreover, the proximal extraction method was mostly ineffective in fully porous femoral stems. A step-by-step approach should be considered for the extraction of a broken stem. The cortical window method can be considered as the second step if proximal extraction methods fail, and ETO should be considered at the last step if all techniques fail.

Early Surgical Complications of Total Hip Arthroplasty in Patients With Morbid Obesity: Propensity-Matched Cohort Study of 3683 Patients

BACKGROUND

The aim of this study is to determine whether the high risk of surgical complications within 1 year of total hip arthroplasty (THA) is due to associated comorbidities or morbid obesity alone as measured by body mass index (BMI ≥ 40 kg/m²).

METHODS

Population-based retrospective cohort study was conducted of all adults in Ontario undergoing primary THA for osteoarthritis (2012-2018). All patients were followed for 1 year. Outcomes were compared among matched groups (hypertension, diabetes, chronic obstructive pulmonary disease, frailty, congestive heart failure, coronary artery disease, asthma, and Charlson score). Primary outcome measure was major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, and revision surgery).

RESULTS

A total of 3683 patients with morbid obesity were matched and had a significantly greater risk of major complications within 1-year (132 [3.6%] vs 54 [1.5%]; hazard ratio [HR] 2.54, 95% confidence interval [CI]; 1.98-3.25). This included greater risk for deep infection requiring surgery (100 [2.8%] vs 26 [0.7%]; HR 3.85, 95% CI; 2.70-45.48) and revision arthroplasty (86 [2.4%] vs 34 [0.9%]; HR 2.61, 95% CI; 1.92-3.55). Operative time was also longer with a median 116 (99-138) vs 102 (87-121) minutes. There were no significant differences in hospital stay, cost of acute care episode, or medical complications.

CONCLUSION

Patients' large body habitus seems to contribute to the increased risk of surgical complications within 1-year of THA. Future research is needed to identify ways of mitigating surgical complications such as centralizing care for this complex group of patients in specialist centers.