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Jud L, Rüedi N, Dimitriou D, Hoch A, Zingg PO. High femoral offset as a risk factor for aseptic femoral component loosening in cementless primary total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2024; 48:1217-1224. [PMID: 38388804 PMCID: PMC11001651 DOI: 10.1007/s00264-024-06116-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
PURPOSE Lateralized stems in primary cementless total hip arthroplasty (THA) showed to be associated with aseptic femoral loosening. However, femoral head length also affects femoral offset but was not considered so far. This study analyzed the impact of high femoral offset (hFO) combinations, formed by lateralized stems or large femoral head lengths, on aseptic femoral component loosening. METHODS Retrospective cohort study was performed including all patients that underwent primary cementless THA at our institution between July 2004 and December 2016. Patients were screened for aseptic femoral component loosening and grouped in aseptic loosening (AL) and non-aseptic loosening (nAL) group. Medical records were screened; implant details were noted and classified in hFO and standard femoral offset (sFO) combinations. Supposed risk factors for aseptic loosening were analyzed. RESULTS Two thousand four hundred fifty-nine THA could be included, containing 14 THA (0.6%) with aseptic femoral component loosening. The AL group contained 11 hFO combinations (78.6%), whereas in the nAL group, 1315 hFO combinations (53.8%) were used. Subgroup analysis showed significant difference between two groups for hFO combinations (p = 0.014), age (p = 0.002), NSAR (p = 0.001), and bilateral THA on same day (p = 0.001). The multiple logistic regression analysis showed that hFO combination was the only variable for increased probability of aseptic loosening (OR, 3.7; p = 0.04). CONCLUSION High femoral offset combinations, formed by lateralized stems or large femoral head lengths in our collective of standard straight stems implanted by an anterior approach, show a 3.7-fold increased probability for aseptic femoral component loosening. Adjustment of the postoperative protocol may be considered in these cases to ensure proper stem ingrowth.
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Affiliation(s)
- Lukas Jud
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland.
| | - Nico Rüedi
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Dimitris Dimitriou
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Armando Hoch
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Patrick O Zingg
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
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Meisterhans M, Dimitriou D, Fasser MR, Hoch A, Jud L, Zingg PO. Influence of offset on osseointegration in cementless total hip arthroplasty: A finite element study. J Orthop Res 2024. [PMID: 38376065 DOI: 10.1002/jor.25808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/21/2024]
Abstract
Early aseptic loosening is caused by deficient osteointegration of the femoral stem due to increased micromotions and represents a common mode of failure in uncemented total hip arthroplasty (THA). This study hypothesized that a higher femoral offset, a smaller stem size and obesity increase femoral micromotion, potentially resulting in early aseptic loosening. A finite element analysis was conducted based on computed tomography segmented model of four patients who received a THA with a triple-tapered straight stem (Size 1, 3, 6). The influence of femoral stem offset (short neck, standard, lateral), head length (S to XXL), femoral anteversion and obesity during daily activities of fast walking and stair climbing was analyzed. The micromotions for the femoral stem zones were compared to a threshold representing a value above which only partial osseointegration is expected. The minimum femoral offset configuration compared to the maximum offset configuration (short neck stem, S head vs. lateral stem, XXL head) leads to a relative mean micromotion increase of 24% for the upper stem zone. Increasing the body weight (body mass index 30-35 kg/m2 ) increases the micromotion by 20% for all stem zones. The obese population recorded threshold-exceeding micromotions for stem sizes 1 and 3 for all offset configurations during stair climbing. Higher femoral offset, a smaller stem size, and higher loading due to obesity lead to an increase in micromotion between the prosthesis and proximal femur and represent a risk configuration for impaired osseointegration of a triple-tapered straight stem, especially when these three factors are present simultaneously.
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Affiliation(s)
- Michel Meisterhans
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dimitris Dimitriou
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Institute of Biomechanics, Balgrist Campus, ETH Zurich, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armando Hoch
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lukas Jud
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick O Zingg
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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McConnell JS, Syed FA, Saunders P, Kattimani R, Ugwuoke A, Magra M, Young SK. Definition and validation of a system for classifying the undersized Corail femoral stem in total hip arthroplasty. Hip Int 2022; 32:737-746. [PMID: 33721509 DOI: 10.1177/1120700021996001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The uncemented total hip arthroplasty relies on a secure initial fixation of the femoral stem to achieve osseointegration. Undersizing of the femoral implant compromises this. Surgeons routinely review postoperative radiographs to assess appropriate sizing, but existing methods of assessment lack standardisation. We present a system of accurately and reliably classifying radiological undersizing, which will help us better understand the factors that might have led to undersizing. AIM To describe and evaluate a classification system for assessing radiological undersizing of the uncemented stem in hip arthroplasty. METHOD We conducted a retrospective review of 1,337 consecutive hip arthroplasties using the Corail stem. Two independent investigators reviewed post-operative radiographs and classified them as either appropriately sized or undersized. Undersized stems were sub-categorised into four subtypes: uniformly undersized, varus undersized, valgus undersized or 'cocktail-glass' undersized. Inter- and intra-observer agreement was determined. The accuracy of our classification system was validated by comparison with digital re-templating. We further assessed patient demographics and stem size in relation to sizing. RESULTS 1 in 5 cases (19.75%) were deemed radiologically undersized. The commonest subtypes of undersizing were uniformly (47%) and varus (39%) undersized. When assessing sizing and subtype categorisation, inter-observer agreement was 89-92% and intra-observer agreement 86%. Classification decisions showed 92% and 97% accuracy for uniformly undersizing and varus undersizing respectively when validated against digital re-templating. Age, gender and smaller stem size were significantly associated with radiological undersizing. The Corail KLA model (125° neck) was found to have a higher incidence of stems undersized in varus. CONCLUSIONS This study describes and validates a classification system for the analysis of radiological undersizing.
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Affiliation(s)
| | | | | | | | | | - Merzesh Magra
- University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, UK
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Karayiannis PN, Cassidy RS, Isaac G, Hughes I, Hill JC, Machenaud A, Beverland DE. Risk Factors for Significant Radiolucent Line Development in a Fully Coated Hydroxyapatite Stem. J Arthroplasty 2021; 36:3709-3715. [PMID: 34303582 DOI: 10.1016/j.arth.2021.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The risk factors for and clinical impact of radiolucent lines (RLLs) in cementless total hip arthroplasty remain contentious. The aim of this work was to describe a method of classification that has clinical significance and to identify risk factors. METHODS A cohort of 288 subjects with unrevised Corail stems (DePuy Synthes, Warsaw, IN) were reviewed with radiographs and Oxford Hip Scores at 10 years. Based on clinical experience, three groups were defined; those with no RLLs (NoRLLs), those considered to have benign RLLs (BenRLLs), and those considered to have significant RLLs (SigRLLs). SigRLLs were then compared to BenRLLs and NoRLLs to determine the validity of this classification. RESULTS One hundred and nine (37.8%) had NoRLLs, 111 (38.5%) had BenRLLs, and 68 (23.6%) had SigRLLs. No significant difference apart from gender was noted between the occurrence of BenRLLs and NoRLLs after multinomial regression analysis, consequently the NoRLLs and BenRLLs groups were combined (NoSigRLLs) and compared to SigRLLs. Non-cross-linked polyethylene (odds ratio = 4.6, P < .001), collarless stem design (odds ratio = 9.4, P < .001), undersizing (odds ratio = 1.2, P = .028), and male sex (odds ratio = 2.1, P = .008) were risk factors for SigRLLs. Regression analysis also revealed that increasing age at operation decreased the likelihood of SigRLLs (P < .001). Patients with SigRLLs had significantly higher pain scores (P = .005) although overall Oxford Hip Scores were not significantly different (P = .364). CONCLUSION The definition of SigRLLs proposed in this study was significantly associated with that of non-cross-linked polyethylene, absence of a collar, undersizing, and higher pain scores.
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Affiliation(s)
- Paul N Karayiannis
- Trauma and Orthopaedics, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | - Roslyn S Cassidy
- Trauma and Orthopaedics, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | - Graham Isaac
- Professor of Medical Engineering, Institute of Medical & Biological Engineering, University of Leeds, United Kingdom
| | | | - Janet C Hill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | | | - David E Beverland
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
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Al-Dirini RMA, Martelli S, Huff D, Zhang J, Clement JG, Besier T, Taylor M. Evaluating the primary stability of standard vs lateralised cementless femoral stems - A finite element study using a diverse patient cohort. Clin Biomech (Bristol, Avon) 2018; 59:101-109. [PMID: 30219523 DOI: 10.1016/j.clinbiomech.2018.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/03/2018] [Accepted: 09/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Restoring the original femoral offset is desirable for total hip replacements as it preserves the original muscle lever arm and soft tissue tensions. This can be achieved through lateralised stems, however, the effect of variation in the hip centre offset on the primary stability remains unclear. METHODS Finite element analysis was used to compare the primary stability of lateralised and standard designs for a cementless femoral stem (Corail®) across a representative cohort of male and female femora (N = 31 femora; age from 50 to 80 years old). Each femur model was implanted with three designs of the Corail® stem, each designed to achieve a different degree of lateralisation. An automated algorithm was used to select the size and position that achieve maximum metaphyseal fit for each of the designs. Joint contact and muscle forces simulating the peak forces during level gait and stair climbing were scaled to the body mass of each subject. FINDINGS The study found that differences in restoring the native femoral offset introduce marginal differences in micromotion (differences in peak micromotion <21 μm), for most cases. Nonetheless, significant reduction in the interfacial strains (>3000 με) was achieved for some subjects when lateralized stems were used. INTERPRETATION Findings of this study suggest that, with the appropriate size and alignment, the standard offset design is likely to be sufficient for primary stability, in most cases. Nonetheless, appropriate use of lateralised stems has the potential reduce the risk of peri-prosthetic bone damage. This highlights the importance of appropriate implant selection during the surgical planning stage.
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Affiliation(s)
- Rami M A Al-Dirini
- Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide 5043, Australia.
| | - Saulo Martelli
- Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide 5043, Australia
| | - Daniel Huff
- DePuy Synthes, Johnson and Johnson, Warsaw, USA
| | - Ju Zhang
- Auckland Bioengineering Institute, The University Auckland, Auckland, New Zealand
| | - John G Clement
- Melbourne Dental School, The University of Melbourne, Melbourne, Australia
| | - Thor Besier
- Auckland Bioengineering Institute, The University Auckland, Auckland, New Zealand
| | - Mark Taylor
- Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide 5043, Australia.
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Brumat P, Pompe B, Antolič V, Mavčič B. The impact of canal flare index on leg length discrepancy after total hip arthroplasty. Arch Orthop Trauma Surg 2018; 138:123-129. [PMID: 29134317 DOI: 10.1007/s00402-017-2840-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The femoral stem should protrude from femur by an appropriate vertical distance to allow leg length equalization at hip arthroplasty; this distance depends on the size/shape of medullary canal and implant. The relationship between femoral morphology and achievability of leg length restoration is currently unclear. Our aim was to examine the impact of the femoral canal flare index (CFI) on the risk of leg length discrepancy (LLD) after total hip arthroplasty with different femoral stems. MATERIALS AND METHODS The study cohort included 126 patients with unilateral primary total hip arthroplasty due to idiopathic osteoarthritis and three different types of implanted femoral stems. The impact of CFI on postoperative LLD was assessed with separate logistic regression model for each implant and covariables of age, gender, body mass index and femoral neck resection level. RESULTS Higher CFI was an independent risk factor for postoperative LLD ≥ 5 mm with odds ratio 4.5 (p = 0.03) in 49 stems with cementless metaphyseal fixation Implantcast-EcoFit®, regardless of the femoral neck resection level. CFI had no significant impact on LLD in 30 stems with cementless diaphyseal fixation EndoPlus-Zweymüller® or 47 cemented collared stems Link-SPII®. No significant difference was observed between groups in pre/postoperative WOMAC scores, postoperative radiographic LLD, subjectively reported LLD, insole use or complications after mean 6.8 years of follow-up. CONCLUSIONS Higher CFI increases the risk of clinically detectable postoperative LLD in single-wedge femoral stems with cementless metaphyseal fixation. CFI has no significant impact on LLD in femoral stems with cementless diaphyseal fixation or cemented fixation.
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Affiliation(s)
- Peter Brumat
- University Medical Centre Ljubljana and Faculty of Medicine, Zaloška 9, 1000, Ljubljana, Slovenia
| | - Borut Pompe
- University Medical Centre Ljubljana and Faculty of Medicine, Zaloška 9, 1000, Ljubljana, Slovenia
| | - Vane Antolič
- University Medical Centre Ljubljana and Faculty of Medicine, Zaloška 9, 1000, Ljubljana, Slovenia
| | - Blaž Mavčič
- University Medical Centre Ljubljana and Faculty of Medicine, Zaloška 9, 1000, Ljubljana, Slovenia.
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