1
|
Brandl M, Jahnke A, Fölsch C, Rickert M, Ishaque BA. Mid- to long-term periprosthetic bone density changes after cementless short stem hip arthroplasty in elderly: A clinical and radiological analysis. J Orthop 2024; 57:17-22. [PMID: 38948502 PMCID: PMC11208799 DOI: 10.1016/j.jor.2024.06.003] [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: 05/25/2024] [Accepted: 06/01/2024] [Indexed: 07/02/2024] Open
Abstract
Introduction Short stem prostheses were originally designed for younger and more active patients. In recent years, they have been increasingly offered to older patients. This study evaluates the mid-to long-term survival of a short stem prosthesis and the changes in periprosthetic bone density following implantation of a cementless short hip stem in patients over 60 years of age. Methods 118 patients aged over 60 received short stem prostheses. Clinical examination included Harris Hip Score (HHS) and Hip Disability and Osteoarthritis Outcome Score (HOOS). 93 patients were followed clinically for at least five years. 53 patients underwent dual-energy x-ray absorptiometry (DXA) and radiographic evaluation. Follow-up intervals were preoperative and postoperative (t0), at approximately six months (t1), at approximately two years (t2), and at approximately five years or later (t3). Results Over a mean 6.7-year observation period for all 118 patients, one stem revision occurred due to a traumatic periprosthetic stem fracture. The five-year survival rate for the endpoint survival of the Metha® stem in 95 at-risk patients is 99.2%. HHS improved significantly from t0 55.3 ± 11.5 (range 30-79) to t3 95.3 ± 8.6 (range 57-100) at a mean of 8.0 years (p < 0.001). HOOS improved significantly in each subscale (p < 0.001). Bone mineral density (BMD) was available for review in 53 patients after a mean of 7.1 years. BMD increased from t0 to t3 in region of interest (ROI) 3 (+0.4%) and ROI 6 (+2.9%) and decreased in ROI 1 (-10.3%), ROI 2 (-9.8%), ROI 4 (-5.3%), ROI 5 (-3.4%) and ROI 7 (-23.1%). Conclusions The evaluated short stem prosthesis shows a remarkably high survival rate in elderly patients, accompanied by excellent clinical results. Load transfer measurements show a metaphyseal-diaphyseal pattern with a trend towards increased diaphyseal transfer over the period observed.
Collapse
Affiliation(s)
- Max Brandl
- Laboratory of Biomechanics, Justus-Liebig-University Giessen, Klinikstrasse 29, 35392, Giessen, Germany
| | - Alexander Jahnke
- Laboratory of Biomechanics, Justus-Liebig-University Giessen, Klinikstrasse 29, 35392, Giessen, Germany
| | - Christian Fölsch
- Laboratory of Biomechanics, Justus-Liebig-University Giessen, Klinikstrasse 29, 35392, Giessen, Germany
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM), Klinikstrasse 33, 35392, Giessen, Germany
| | - Markus Rickert
- Laboratory of Biomechanics, Justus-Liebig-University Giessen, Klinikstrasse 29, 35392, Giessen, Germany
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM), Klinikstrasse 33, 35392, Giessen, Germany
| | - Bernd Alexander Ishaque
- Laboratory of Biomechanics, Justus-Liebig-University Giessen, Klinikstrasse 29, 35392, Giessen, Germany
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM), Klinikstrasse 33, 35392, Giessen, Germany
| |
Collapse
|
2
|
Stauss R, Becker NT, Savov P, Ettinger M, Seeber GH. Analysis of Postoperative Complication and Revision Rates and Mid- to Long-Term Implant Survival in Primary Short-Stem Total Hip Arthroplasty. J Clin Med 2024; 13:3779. [PMID: 38999347 PMCID: PMC11242722 DOI: 10.3390/jcm13133779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/18/2024] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Short-stem prostheses were introduced as an alternative to conventional straight-stem prostheses. Despite their benefits, including minimally invasive approaches, soft-tissue- and bone-sparing implantation, and physiological load transfer to the metaphysis, data on postoperative complication and revision rates as well as on implant survival are scarce. Methods: A retrospective analysis of 1327 patients who underwent primary total hip arthroplasty (THA) using the Metha® short stem between 2006 and 2023 was conducted. Complication and revision rates were analysed for the intraoperative, direct postoperative, and follow-up episodes. Implant survival was analysed with the endpoint of all-cause stem revision. Results: Intraoperative complications were observed in 3.77% of the cases and included 44 hairline cracks and 6 fractures. In 15 cases (30.0%), conversion to a straight-stem or revision implant was necessary. The direct postoperative complication rate was 2.44%, and 11 revision procedures were performed during inpatient stay (0.84%). Mean follow-up was 7 years (range 1-17). During follow-up, femoral component revision was performed in 60 cases. Aseptic loosening and stem subsidence accounted for a combined percentage of 80% of all indications. Implant survival rate was 95.66% after 5 years, 95.58% after 10 years, and 95.50% after 15 years. Conclusions: Our study provides a comprehensive analysis of postoperative complication and revision rates in a large sample undergoing primary short-stem THA. Postoperative complication rates were favourable, and the long-term implant survival rates were comparable to conventional straight-stem prostheses. Therefore, short-stem THA may be considered an alternative for younger patients.
Collapse
Affiliation(s)
- Ricarda Stauss
- Division of Orthopaedics at Campus Pius-Hospital, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, 26121 Oldenburg, Germany
| | - Nils T. Becker
- Division of Orthopaedics at Campus Pius-Hospital, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, 26121 Oldenburg, Germany
| | - Peter Savov
- Division of Orthopaedics at Campus Pius-Hospital, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, 26121 Oldenburg, Germany
| | - Max Ettinger
- Division of Orthopaedics at Campus Pius-Hospital, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, 26121 Oldenburg, Germany
| | - Gesine H. Seeber
- Division of Orthopaedics at Campus Pius-Hospital, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, 26121 Oldenburg, Germany
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| |
Collapse
|
3
|
Diaz-Lopez RA, Wen PH, Shelton JC. Influence of Taper surface topographies on contact deformation and stresses. J Mech Behav Biomed Mater 2023; 148:106213. [PMID: 37952504 DOI: 10.1016/j.jmbbm.2023.106213] [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] [Received: 01/02/2023] [Revised: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023]
Abstract
The role of bore and trunnion surface topography on the failure rate of total hip joint replacements due to trunnionosis is not clear despite significant variations in the design of taper components between manufacturers. Taper surface topography, along with other taper design parameters such as clearance, diameter, and assembly force, determine the initial interlock of the contacting surfaces after assembly; this has been related to relative motions that can cause fretting and corrosion at the taper interface. However, in most in-silico parametrical taper studies associated with taper micromotions, the bore and trunnion surfaces have been simplified using a flat surface and/or sinusoidal functions to mimic the surface roughness. The current study tests the hypothesis that the use of simple geometrical functions for the taper surface topography can predict the surface mechanics developed in assembled tapers. Measured and simulated surfaces of bores and trunnions were characterised using common roughness parameters and spectral density estimations. Using the same characterised surface profiles, 2D Finite Element (FE) models of CoCr alloy femoral heads and Ti alloy trunnions were developed. Models simulated assembly conditions at different resultant forces ranging from 0.5 to 4.0 kN, contact conditions were determined and associated with their topographical characteristics. Measured surfaces of bore and trunnion components comprise up to seven dominant spatial frequencies. Flattening of the trunnion microgrooved peaks was observed during the assembly of the taper. When the femoral head bore and trunnion topography were both considered a reduced number of microgrooved peaks were in contact, from 51 in an idealised taper surfaces to 35 in measured surfaces using an assembly reaction force of 4 kN. The contact points in the models developed high plastic strains, which were greater than that associated with failure of the material. Results showed that line and sine wave functions over estimate contact points at the taper interface compared to those surfaces that consider roughness and peak variation. These findings highlight the important role of modelling the full surface topography on the taper contact mechanics, as surface variations in the roughness and waviness change the performance of tapers.
Collapse
Affiliation(s)
- R A Diaz-Lopez
- School of Engineering and Materials Science, Queen Mary University of London, UK
| | - P H Wen
- School of Engineering and Materials Science, Queen Mary University of London, UK
| | - J C Shelton
- School of Engineering and Materials Science, Queen Mary University of London, UK.
| |
Collapse
|
4
|
Abstract
» Metallosis is a rare but significant complication that can occur after total hip arthroplasty (THA) for a variety of reasons but most commonly in patients with metal-on-metal implants.» It is characterized by the visible staining, necrosis, and fibrosis of the periprosthetic soft tissues, along with the variable presence of aseptic cysts and solid soft tissue masses called pseudotumors secondary to the corrosion and deposition of metal debris.» Metallosis can present with a spectrum of complications ranging from pain and inflammation to more severe symptoms such as osteolysis, soft tissue damage, and pseudotumor formation.» Workup of metallosis includes a clinical evaluation of the patient's symptoms, imaging studies, serum metal-ion levels, and intraoperative visualization of the staining of tissues. Inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein along with intraoperative frozen slice analysis may be useful in certain cases to rule out concurrent periprosthetic joint infection.» Management depends on the severity and extent of the condition; however, revision THA is often required to prevent rapid progression of bone loss and tissue necrosis.
Collapse
Affiliation(s)
- Anderson Lee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | |
Collapse
|
5
|
Pautasso A, Bardellini G, Stissi P, D’Angelo F. Usefulness of modular neck adapter in partial hip revision. ANNALS OF JOINT 2023; 8:35. [PMID: 38529235 PMCID: PMC10929363 DOI: 10.21037/aoj-23-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 09/08/2023] [Indexed: 03/27/2024]
Abstract
Background and Objective Modular neck adapters allow different length and offset changes to reach a stable total hip arthroplasty (THA) and permit a quick partial hip revision procedure without removing the existing components. The literature is poor on this matter and about the long-term related outcomes. This narrative review summarizes the most recent literature about these devices as an option of surgical treatment in partial total hip arthroplasty revision (THAr) focusing on indications, clinical and radiological outcomes, and related complications. Methods The narrative review of the current available literature was conducted in December 2022 through electronic database. The terms used were: "Head neck taper" OR "Merete BioBall" AND "revision Total Hip Arthroplasty (MeSH Terms)". The timeframe was limited between 01/01/2000 and 01/12/2022. The studies regarding the clinical use of the Merete BioBall® system in hip revision surgery were included, while all the papers concerning modular stem prosthesis were excluded. Key Content and Findings The surgical procedure is safe, quick and allows the surgeon to correct a well-fixed stem version, length and offset, besides retensioning soft tissues. Clinical and radiological outcomes are good with low complications rates. Conclusions The modular neck adapter system seems to be a good surgical procedure for recurrent dislocation of THA, especially in case of a second THAr surgery. However, the main indication of adapter use remains the isolated acetabular cup revision. The related complications are rare: the worst is the re-dislocation due to an insufficient stem version and length correction. Re-dislocation rates reported in literature vary from 5.2% to 15%. Corrosion or fretting of the modular system are not reported in literature.
Collapse
Affiliation(s)
- Andrea Pautasso
- Orthopaedic and Traumatology Department, ASST Sette Laghi, Circolo Hospital and Macchi Foundation in Varese, University Center, Varese, Italy
| | - Giuseppe Bardellini
- Orthopaedic and Traumatology Department, University of Studies Insubria, Varese, Italy
| | - Placido Stissi
- Orthopaedic and Traumatology Department, ASST Sette Laghi, Circolo Hospital and Macchi Foundation in Varese, University Center, Varese, Italy
| | - Fabio D’Angelo
- Orthopaedic and Traumatology Department, ASST Sette Laghi, Circolo Hospital and Macchi Foundation in Varese, University Center, Varese, Italy
- Department of Biotechnology and Life Sciences (DBSV), University of Studies Insubria, Varese, Italy
| |
Collapse
|
6
|
Murphy B, Baez J, Morris MA. Characterising Hydroxyapatite Deposited from Solution onto Novel Substrates: Growth Mechanism and Physical Properties. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 13:2483. [PMID: 37686991 PMCID: PMC10489777 DOI: 10.3390/nano13172483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Abstract
Whilst titanium, stainless steel, and cobalt-chrome alloys are the most common materials for use in orthopaedic implant devices, there are significant advantages in moving to alternative non-metallic substrates. Substrates such as polymers may have advantageous mechanical biological properties whilst other substrates may bring unique capability. A key challenge in the use of non-metal products is producing substrates which can be modified to allow the formation of well-adhered hydroxyapatite films which promote osteointegration and have other beneficial properties. In this work, we aim to develop methodology for the growth of hydroxyapatite films on surfaces other than bulk metallic parts using a wet chemical coating process, and we provide a detailed characterisation of the coatings. In this study, hydroxyapatite is grown from saturated solutions onto thin titanium films and silicon substrates and compared to results from titanium alloy substrates. The coating process efficacy is shown to be dependent on substrate roughness, hydrophilicity, and activation. The mechanism of the hydroxyapatite growth is investigated in terms of initial attachment and morphological development using SEM and XPS analysis. XPS analysis reveals the exact chemical state of the hydroxyapatite compositional elements of Ca, P, and O. The characterisation of grown hydroxyapatite layers by XRD reveals that the hydroxyapatite forms from amorphous phases, displaying preferential crystal growth along the [002] direction, with TEM imagery confirming polycrystalline pockets amid an amorphous matrix. SEM-EDX and FTIR confirmed the presence of hydroxyapatite phases through elemental atomic weight percentages and bond assignment. All data are collated and reviewed for the different substrates. The results demonstrate that once hydroxyapatite seeds, it crystallises in the same manner as bulk titanium whether that be on a titanium or silicon substrate. These data suggest that a range of substrates may be coated using this facile hydroxyapatite deposition technique, just broadening the choice of substrate for a particular function.
Collapse
Affiliation(s)
- Bríd Murphy
- Advanced Materials & Bioengineering Research Centre (AMBER), Trinity College Dublin, Dublin 2, D02 CP49 Dublin, Ireland;
- School of Chemistry, Trinity College Dublin, Dublin 2, D02 PN40 Dublin, Ireland
| | - Jhonattan Baez
- Advanced Materials & Bioengineering Research Centre (AMBER), Trinity College Dublin, Dublin 2, D02 CP49 Dublin, Ireland;
- School of Chemistry, Trinity College Dublin, Dublin 2, D02 PN40 Dublin, Ireland
| | - Mick A. Morris
- Advanced Materials & Bioengineering Research Centre (AMBER), Trinity College Dublin, Dublin 2, D02 CP49 Dublin, Ireland;
- School of Chemistry, Trinity College Dublin, Dublin 2, D02 PN40 Dublin, Ireland
| |
Collapse
|
7
|
Castagnini F, Bordini B, Lucchini S, Cosentino M, Tassinari E, Traina F. Mid-term outcomes of revision hip arthroplasty due to titanium modular neck failure. Arch Orthop Trauma Surg 2023; 143:5909-5918. [PMID: 36764965 DOI: 10.1007/s00402-023-04805-1] [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: 12/01/2022] [Accepted: 01/29/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION The current strategy for modular neck failures in total hip arthroplasty (THA) is calibrated on CrCo neck failures. Stem revision is usually required, but the procedure is challenging and achieves modest outcomes (up to 20% of re-revisions at short-term). No study reports revision strategies and outcomes after Ti neck failures. Aims of the study were to evaluate: (1) demographic and implant features of the cohort to be revised, (2) intra-operative findings and surgical revision strategies and (3) clinical and radiological post-revision outcomes. MATERIALS AND METHODS Hospital database was enquired about revisions due to Ti neck failures in primary THAs. Sixty-five revisions were enrolled (all with the same modular system). Neck exchange was attempted as the first-line treatment. Patients were clinically and radiographically evaluated after revision. RESULTS The revision cohort encompassed fatigue neck fractures occurred 4.4 ± 2.6 years after THA: patients < 65 years and/or > 80 kg (98.5%) were predominant. Fifty-three neck exchanges were performed (81.5%). Eleven failures required stem revisions (16.9%), generally due to demanding neck extraction. Six complications occurred after neck exchange (11.3%), among them 2 acute infections requiring surgery (3.8%). Among stem revisions, one aseptic loosening and one neck re-fracture (18.5%) required re-revisions. At a mean follow-up of 7.1 ± 4 years, the neck exchange cohort achieved a mean HHS of 89.1 ± 6.3 (stem revisions: 84.1 ± 10.9). CONCLUSIONS Revisions for Ti neck failures were predominantly performed due to fatigue fractures. In case of failures, neck exchange is a feasible procedure in most of the cases, with good outcomes at 7 years. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Francesco Castagnini
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d'anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy.
| | - Barbara Bordini
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136, Bologna, Italy
| | - Stefano Lucchini
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d'anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Monica Cosentino
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136, Bologna, Italy
| | - Enrico Tassinari
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d'anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Francesco Traina
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d'anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
- Orthopaedics and Traumatology, DIBINEM University of Bologna, Bologna, Italy
| |
Collapse
|
8
|
Bruschetta A, Palco M, Fenga D, Giuca G, Holzer LA, Alito A, Cacciola G, De Meo F, Cavaliere P. How to Manage Metallosis: A Retrospective Cohort Analysis after Revision Hip Surgery. J Clin Med 2023; 12:4809. [PMID: 37510924 PMCID: PMC10381485 DOI: 10.3390/jcm12144809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Adverse local tissue reactions to metal debris are due to a metal-on-metal bearing complication caused by micromotions at modular interfaces that induce corrosion of the protective oxide layer. This process could lead to wear, fretting, and abrasion with the release of metal ions locally and systemically, which may cause adverse local reactions in nearby tissues. The aim of this study is to describe a series of patients with painful local adverse tissue reactions secondary to corrosion at the modular neck-body interface, to document the clinical presentation, diagnostic workup, and surgical findings of our research, and to search for a possible correlation between metallosis and infection. METHODS A retrospective study of patients with adverse local tissue reactions due to metal surface corrosion was performed. Blood samples were collected to identify erythrocyte sedimentation rate, C reactive protein, and procalcitonin, and a magnetic resonance imaging protocol was performed. RESULTS Serum cobalt and chromium levels of the 43 patients tested were significantly higher on average. However, both erythrocyte sedimentation rate and C-reactive protein were significantly elevated. Magnetic resonance imaging showed adverse reactions to metal debris with large soft tissue masses and surrounding tissue damage. CONCLUSIONS Corrosion in hip prosthesis can lead to the release of metal ions and debris locally and systemically, resulting in local soft tissue changes. A "tumor-like" debridement can reduce this complication.
Collapse
Affiliation(s)
| | - Michelangelo Palco
- Department of Orthopaedic and Traumatology, Casa di Cura Caminiti, 89018 Villa San Giovanni, Italy
| | - Domenico Fenga
- Section of Orthopaedics and Traumatology, Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, 98122 Messina, Italy
| | - Gabriele Giuca
- Section of Orthopaedics and Traumatology, Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, 98122 Messina, Italy
| | - Lukas A Holzer
- Perth Orthopaedic and Sports Medicine Centre, Perth, WA 6005, Australia
| | - Angelo Alito
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98122 Messina, Italy
| | - Giorgio Cacciola
- Orthopaedic Institute of Southern Italy "Franco Scalabrino", 98165 Messina, Italy
| | - Federico De Meo
- Orthopaedic Institute of Southern Italy "Franco Scalabrino", 98165 Messina, Italy
| | - Pietro Cavaliere
- Orthopaedic Institute of Southern Italy "Franco Scalabrino", 98165 Messina, Italy
| |
Collapse
|
9
|
Zajc J, Fokter SK. Bimodular femoral stems in primary total hip arthroplasty. Expert Rev Med Devices 2023; 20:1051-1064. [PMID: 37753590 DOI: 10.1080/17434440.2023.2264177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/25/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION This review critically examines the efficacy of dual-modular stems in primary total hip arthroplasty. Given the variability and non-comparability of certain femoral stem designs and stem-neck couplings, with some even being withdrawn from the market, this review offers an in-depth analysis of predominant implant performances. AREAS COVERED The paper explores a brief historical summary related to dual-modular stems, including the complications associated with their use, diagnostic tools for evaluation, analysis of both recalled and currently available models, as well as alternative therapeutic options. This information is pertinent for both clinical and research domains. EXPERT OPINION While dual-modular systems were initially touted to offer several advantages, the evidence substantiating these benefits has been ambiguous. Further, these systems introduce the risk of alternative complications. In specific cases involving patients with developmental hip dysplasia and certain proximal femoral deformities requiring complex reconstructions, dual-modular systems might be relevant. Nonetheless, the use of long interchangeable necks in patients with a body mass index above 30 kg/m2 is discouraged, and pairing a long varus-oriented neck with an extra-long femoral head should be avoided in all patients.
Collapse
Affiliation(s)
- Jan Zajc
- Clinical Department of Orthopedic Surgery, University Medical Center Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Samo K Fokter
- Clinical Department of Orthopedic Surgery, University Medical Center Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| |
Collapse
|
10
|
Radaelli M, Buchalter DB, Mont MA, Schwarzkopf R, Hepinstall MS. A New Classification System for Cementless Femoral Stems in Total Hip Arthroplasty. J Arthroplasty 2023; 38:502-510. [PMID: 36122690 DOI: 10.1016/j.arth.2022.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/18/2022] [Accepted: 09/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The growing variety of total hip arthroplasty implants necessitates a standardized, simple, and brand-neutral language to precisely classify femoral components. Although previous classifications have been useful, they need updating to include stems that have current surface treatment technologies, modularity, collar features, and other geometric characteristics. METHODS To accomplish this, we propose a new classification system for stems based on 3 distinguishing stem features: (1) geometry, (2) location of modularity, and (3) length. RESULTS Our system allows for the easy classification of all currently used stem types. CONCLUSIONS One goal of this endeavor is to improve clinical record keeping to facilitate study comparisons as well as literature reviews.
Collapse
Affiliation(s)
- Marco Radaelli
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Daniel B Buchalter
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | | |
Collapse
|
11
|
Martelli A, Erani P, Pazzagli N, Cannillo V, Baleani M. Surface Analysis of Ti-Alloy Micro-Grooved 12/14 Tapers Assembled to Non-Sleeved and Sleeved Ceramic Heads: A Comparative Study of Retrieved Hip Prostheses. MATERIALS (BASEL, SWITZERLAND) 2023; 16:1067. [PMID: 36770073 PMCID: PMC9920329 DOI: 10.3390/ma16031067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
Ti6Al4V titanium alloy (Ti-alloy) sleeved ceramic heads have become widely used in revision surgery when the hip stem is left in situ. This solution guarantees a new junction between the bore of the ceramic head and the Ti-alloy sleeve, regardless of any possible, slight surface damage to the Ti-alloy taper of the stem. However, this solution introduces an additional Ti-alloy/Ti-alloy interface pairing, which is potentially susceptible to mechanically assisted crevice corrosion. This study evaluated both qualitatively and quantitatively the damage that occurred in vivo on Ti-alloy micro-grooved 12/14 tapers of (i) primary implants with non-sleeved ceramic heads (Group 1), (ii) secondary implants with non-sleeved ceramic heads (Group 2), and (iii) secondary implants with sleeved ceramic heads (Group 3). A total of 45 explants-15 for each group, including short-, medium- and long-neck heads-underwent optical evaluation for surface damage (Goldberg scoring), surface roughness analysis, and SEM/EDX analysis. The Goldberg scores did not reveal different patterns in the tapers' surface damage; surface damage was classified as absent or mild (surface damage score ≤2) in 94%, another 94%, and 92% of the analysed regions for Group 1, Group 2, and Group 3, respectively. Small but significant differences in morphological changes occurred in the tapers of the three groups: reductions no greater than a few percentage points in median values of roughness parameters were found in Group 1 and Group 2, while negligible changes were found in Group 3. SEM/EDX analysis revealed little (i.e., a slight increase in the oxygen content) to undetectable changes in the chemical composition on the Ti-alloy surface independently of the group. These results suggest that the Ti-alloy/Ti-alloy sleeve/taper junction is only mildly susceptible to mechanically assisted crevice corrosion. Assembling a sleeved ceramic head, with variable neck lengths up to a "long-neck", to a Ti-alloy micro-grooved 12/14 taper of a stem left in situ does not seem to increase the risk of revision due to trunnionosis, as long as junction stability (i.e., the proper seating of the sleeved ceramic head on the 12/14 taper) is achieved intraoperatively.
Collapse
Affiliation(s)
- Andrea Martelli
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Dipartimento di Ingegneria Enzo Ferrari, Università degli Studi di Modena e Reggio Emilia, 41125 Modena, Italy
| | - Paolo Erani
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Nicola Pazzagli
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Valeria Cannillo
- Dipartimento di Ingegneria Enzo Ferrari, Università degli Studi di Modena e Reggio Emilia, 41125 Modena, Italy
| | - Massimiliano Baleani
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| |
Collapse
|
12
|
Bäcker HC, Wu CH, Kienzle A, Perka C, Gwinner C. Mechanical failure of total hip arthroplasties and associated risk factors. Arch Orthop Trauma Surg 2023; 143:1061-1069. [PMID: 35088168 PMCID: PMC9925486 DOI: 10.1007/s00402-022-04353-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 01/06/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Mechanical failure of total hip arthroplasties is a rare but devastating complication. With increasing numbers in primary arthroplasty implantation, revision surgeries are indicated more often. Therefore, understanding the mechanism and the location of failure is essential in determining proper treatment. Aim of this study was to identify mechanical failures of all total hip arthroplasties performed in a major academic center as well as the associated risk factors such as BMI and sports. METHODS A retrospective trial was conducted using our prospective arthroplasty database. Database was searched for all patients presenting with mechanical failures of total hip arthroplasty (THA) to the emergency department between 2011 and 2019. All medical charts and radiographs as well as surgical reports were analyzed to identify demographics, implant choice in addition to location of failure and subsequent treatment. RESULTS In total, 13 patients suffering from mechanical total hip implant failure were found. The femoral neck (conus) was broken in four patients, the stem in five cases, one broken inlay, two cup failures and one conus dislocation. The mean BMI was 31.42 ± 5.29 kg/m2 including five patients who have obesity class II. In all cases, revision surgeries were indicated. No structural causes or underlying risk factors such as repeated physical load (i.e. in sports) were identified. CONCLUSION Implant failure does not seem to correlate with participation in sports or BMI. Catastrophic failure of implants is a technical challenge requiring special extraction instruments that can be difficult even for experienced surgeons. It should be noted that functional outcome is often worse for this group of patients after surgery than comparing against those revised for loosening. LEVEL OF EVIDENCE III, Retrospective Trial.
Collapse
Affiliation(s)
- Henrik C. Bäcker
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Chia H. Wu
- Department of Orthopedics and Sports Medicine, Baylor College of Medicine Medical Center, Houston, TX USA
| | - Arne Kienzle
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Carsten Perka
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Clemens Gwinner
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117 Berlin, Germany
| |
Collapse
|
13
|
Dun S, Lim BH, Swope SW, Whitaker DR. A novel method to improve femoral head and stem taper stability intraoperatively in total hip arthroplasty - a proof of concept study. Orthop Traumatol Surg Res 2022; 108:103284. [PMID: 35470121 DOI: 10.1016/j.otsr.2022.103284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 11/29/2021] [Accepted: 01/04/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Mechanically assisted crevice corrosion (MACC) has been associated with the compromised durability and fixation of modular total hip implants, adverse reaction of local tissue, and other undesirable clinical outcomes in total hip arthroplasty (THA). MACC is primarily caused by the relative motion between the femoral head and stem. To minimize the relative motion the taper connection between the two components must be strong enough. The current study addressed the following questions: (1) Does increasing the mass of the femoral stem improve the taper connection strength intraoperatively? (2) Does increasing the mass of the femoral stem reduce the risk of periprosthetic tissue damage intraoperatively? HYPOTHESIS Increasing the mass of the femoral stem improve the taper connection strength intraoperatively. MATERIALS AND METHODS During the experiment, femoral heads were impacted onto the stem tapers with and without an additional weight attached to the stem. The femoral heads were then pulled off to investigate the strength of the taper connection. The stem displacement and acceleration at impaction were also measured to evaluate the risk of periprosthetic tissue damage. RESULTS The results showed that the pull-off force was increased by 24% (p=0.011, n=6) when an additional weight was attached to the stem. The additional weight also reduced the maximum stem acceleration and maximum stem displacement by 37% (p<0.001, n=6) and 14% (p=0.094, n=6), respectively. DISCUSSION These findings suggest that the femoral head and stem taper connection strength can be significantly improved and the risk of periprosthetic tissue damage significantly reduced intraoperatively by attaching an additional weight to the stem to increase its mass. LEVEL OF EVIDENCE III, comparative in vitro mechanical investigation.
Collapse
Affiliation(s)
- Shouchen Dun
- DePuy Synthes Joint Reconstruction, 700 Orthopaedic Drive, Warsaw, IN 46581, USA.
| | - Boon Him Lim
- DePuy Synthes Joint Reconstruction, 700 Orthopaedic Drive, Warsaw, IN 46581, USA
| | - Stephen W Swope
- DePuy Synthes Joint Reconstruction, 700 Orthopaedic Drive, Warsaw, IN 46581, USA
| | - Dustin R Whitaker
- DePuy Synthes Joint Reconstruction, 700 Orthopaedic Drive, Warsaw, IN 46581, USA
| |
Collapse
|
14
|
Long-term survivorship of an exchangeable-neck hip prosthesis with a Ti-alloy/Ti-alloy neck-stem junction. Arch Orthop Trauma Surg 2022; 143:3649-3657. [PMID: 36178493 DOI: 10.1007/s00402-022-04634-8] [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: 12/27/2021] [Accepted: 09/18/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Breakage of exchangeable-neck (EN) and adverse local tissue reactions (ALTRs) to neck-stem junction (NSJ) damage products are responsible for increasing the revision rate of EN hip prostheses. We investigated the survivorship of an EN hip prosthesis including a NSJ with both components made of titanium alloy (Ti-alloy/Ti-alloy) to assess whether, and to what extent, EN breakage and NSJ damage affected implant survivorship. MATERIALS AND METHODS Using data from a hip replacement registry, we determined survivorship of 2857 EN prostheses. Long-offset configurations of head and EN were implanted in heavy (> 90 kg) patients only in 23 hips. We investigated under which conditions EN breakages or ALTRs occurred. We also measured titanium (Ti) and vanadium (V) blood concentrations in 24 patients with a unilateral well-working prosthesis. RESULTS The 17-year survival rates for any reason and aseptic loosening of any component were 88.9% (95%CI 87.5-90.1; 857 hips at risk) and 96.9% (95%CI 96.0-97.6), respectively. There were two cases of EN breakage and one case of ALTR (metallosis), due to rim-neck impingement, out of 276 revisions. After an average period of 9.8 years (range 7.8-12.8 years), the maximum Ti and V blood concentrations in patients with a well-working prosthesis were 5.0 µg/l and 0.16 µg/l, respectively. CONCLUSION The present incidence of EN breakage or ALTR is lower than those reported in other studies evaluating EN hip prosthesis survivorship. This study suggests that (i) the risk of EN breakage is reduced by limiting the use of long-offset configurations in heavy patients and (ii) Ti-alloy/Ti-alloy NSJ damage products do not promote ALTR nor significantly alter the rate of implant loosening. Since design decisions and implant configuration determine the NSJ strength, the NSJ strength in working conditions must be thoroughly investigated to proper define the clinical indications for any EN design.
Collapse
|
15
|
Ghert M. CORR Insights®: What Are the Long-term Surgical Outcomes of Compressive Endoprosthetic Osseointegration of the Femur with a Minimum 10-year Follow-up Period? Clin Orthop Relat Res 2022; 480:549-550. [PMID: 34591037 PMCID: PMC8846350 DOI: 10.1097/corr.0000000000002004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/16/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Michelle Ghert
- Professor, Department of Surgery, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| |
Collapse
|
16
|
McConnell ZA, Stambough JB, Barnes CL, Wilson BL, Mears SC. Cobalt Levels and Pseudotumor Characteristics Vary due to Metal Ion Source: Modular Femoral Neck vs Metal-on-Metal Articulations. J Arthroplasty 2021; 36:3490-3497. [PMID: 34172347 DOI: 10.1016/j.arth.2021.05.018] [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: 03/29/2021] [Revised: 05/05/2021] [Accepted: 05/12/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study examines cobalt levels and pseudotumor characteristics in a non-recalled modular femoral prosthesis. We sought to determine relationships between serum cobalt levels and pseudotumors following modular and metal-on-metal (MoM) total hip arthroplasty (THA), the location and size of pseudotumors, and changes to pseudotumor grade over time. METHODS We retrospectively evaluated a cohort of 190 primary THAs implanted with a dual-modular femoral stem by one surgeon from 2005 to 2013. One hundred seventeen THAs used a cobalt-chromium modular neck (CoCrMN) component and non-MoM articulation, 63 THAs had a titanium neck component and MoM articulation, and 10 had a titanium neck component and polyethylene liner. Serum ion levels were recorded for all patients. Pseudotumor grade and location were measured by musculoskeletal-trained radiologists. RESULTS Cobalt levels did not correlate to time after index arthroplasty. In the CoCrMN group, cobalt levels were elevated in 11 of 19 (57.9%) patients with pseudotumor compared to 14 of 19 (73.7%) in the MoM group. Pseudotumors were more often located lateral to the hip joint in the CoCrMN group compared to anteromedial following MoM arthroplasty. In CoCrMN THAs, pseudotumors were visualized in 12 of 51 (23.5%) initial MARS MRIs within 40 months compared to 5 of 66 (7.6%) performed later (P = .02). CONCLUSION Pseudotumor characteristics differ between patients with CoCrMN designs vs those with an MoM articulation. Normal serum cobalt levels did not exclude the presence of a pseudotumor and routine MARS MRI should be included in follow-up of patients with this CoCrMN prostheses.
Collapse
Affiliation(s)
- Zachary A McConnell
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Becky L Wilson
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| |
Collapse
|
17
|
Badhe RV, Akinfosile O, Bijukumar D, Barba M, Mathew MT. Systemic toxicity eliciting metal ion levels from metallic implants and orthopedic devices - A mini review. Toxicol Lett 2021; 350:213-224. [PMID: 34252509 DOI: 10.1016/j.toxlet.2021.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 06/19/2021] [Accepted: 07/07/2021] [Indexed: 12/28/2022]
Abstract
The metal/metal alloy-based implants and prostheses are in use for over a century, and the rejections, revisions, and metal particle-based toxicities were reported concurrently. Complications developed due to metal ions, metal debris, and organo-metallic particles in orthopedic patients have been a growing concern in recent years. It was reported that local and systemic toxicity caused by such released products from the implants is one of the major reasons for implant rejection and revision. Even though the description of environmental metal toxicants and safety limits for their exposure to humans were well established in the literature, an effort was not adequately performed in the case of implant-based metal toxicology. Since the metal ion concentration in serum acts as a possible indicator of the systemic toxicity, this review summarizes the reported human serum safe limits, toxic limits, and concentration range (μg/L, ppb, etc.) for mild to severe symptoms of six (cardiac, hepatic, neuro, nephron, dermal and endocrine) systemic toxicities for twelve most commonly used metallic implants. It also covers the widely used metal ion quantification techniques and systemic toxicity treatments reported.
Collapse
Affiliation(s)
- Ravindra V Badhe
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - Obakanyin Akinfosile
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - Divya Bijukumar
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | | | - Mathew T Mathew
- Department of Biomedical Sciences, University of Illinois College of Medicine at Rockford, Rockford, IL, USA.
| |
Collapse
|
18
|
Dual Modular Titanium Alloy Femoral Stem Failure Mechanisms and Suggested Clinical Approaches. MATERIALS 2021; 14:ma14113078. [PMID: 34199983 PMCID: PMC8200202 DOI: 10.3390/ma14113078] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022]
Abstract
Titanium (Ti) alloys have been proven to be one of the most suitable materials for orthopaedic implants. Dual modular stems have been introduced to primary total hip arthroplasty (THA) to enable better control of the femoral offset, leg length, and hip stability. This systematic review highlights information acquired for dual modular Ti stem complications published in the last 12 years and offers a conclusive discussion of the gathered knowledge. Articles referring to dual modular stem usage, survivorship, and complications in English were searched from 2009 to the present day. A qualitative synthesis of literature was carried out, excluding articles referring solely to other types of junctions or problems with cobalt-chromium alloys in detail. In total, 515 records were identified through database searching and 78 journal articles or conference proceedings were found. The reasons for a modular neck fracture of a Ti alloy are multifactorial. Even though dual modular stems have not shown any clinical benefits for patients and have been associated with worse results regarding durability than monolithic stems, some designs are still marketed worldwide. Orthopaedic surgeons should use Ti6Al4V dual modular stem designs for primary THA in special cases only.
Collapse
|
19
|
Lex JR, Welch MD, See A, Edwards TC, Stavropoulos NA, Babis GC. Systematic review of primary total hip arthroplasty using titanium-titanium modular-neck prostheses: the true risk of revision. Hip Int 2021; 31:295-303. [PMID: 32297561 DOI: 10.1177/1120700020916870] [Citation(s) in RCA: 6] [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
AIMS Modular-neck femoral implants are used to enable more variability in femoral neck version, offset and length. It has been reported that these implants carry a higher rate of revision. The aim of this review was to assess the overall and cause-specific revision rate of titanium-titanium alloy modular-neck implants in primary total hip arthroplasty (THA). METHODS A systematic review was conducted following PRISMA guidelines and utilising multiple databases. All results were screened for eligibility. Studies published from 2000 onwards, using a current-generation, titanium-titanium, modular-neck implant were included. Overall and cause-specific revision rates were analysed, comparing to fixed-neck prostheses where applicable. RESULTS 920 studies were screened. After applying exclusion criteria, 23 were assessed in full and 14 included. These consisted of 12 case series and 2 joint registry analyses. 21,841 patients underwent a modular-neck implant with a weighted mean follow-up of 5.7 years, mean age of 62.4 years, and average body mass index (BMI) of 28.4kg/m2. The overall revision rate was 3.95% and 2.98% for modular and fixed-neck prostheses, respectively. For studies with >5 years follow-up the mean revision rate was 3.08%. There was no difference in cause-specific revision rates by implant design. Mean improvement in Harris Hip Score was 41.9. CONCLUSIONS At medium-term, revision rates for titanium-titanium primary modular-neck THA are acceptable. These prostheses are a sensible management option in patients with considerable anatomical hip deformity not amenable to correction with standard fixed-neck implants. Patients of male gender, high BMI and requiring prostheses with a larger neck, offset or head are at higher risk of implant failure.
Collapse
Affiliation(s)
- Johnathan R Lex
- Oxford Foundation School, Oxford, UK.,Royal Orthopaedic Hospital, Birmingham, UK
| | - Matthew D Welch
- Oxford Foundation School, Oxford, UK.,Oxford University Clinical Academic Graduate School, Oxford, UK
| | - Abbas See
- Oxford Foundation School, Oxford, UK
| | | | - Nikolaos A Stavropoulos
- 2nd Department of Orthopaedic Surgery, Konstantopouleio General Hospital, National and Kapodistrian University of Athens, Athens Medical School, Athens, Greece.,Department of Orthopaedic Surgery, General Hospital of Karpenissi, Karpenissi, Greece
| | - George C Babis
- 2 Department of Orthopaedic Surgery, Konstantopouleio General Hospital, National and Kapodistrian University of Athens, Athens Medical School, Athens, Greece
| |
Collapse
|
20
|
Bilateral neck fracture in bimodular femoral stem after primary total hip arthroplasty: a case report. BMC Musculoskelet Disord 2021; 22:356. [PMID: 33863307 PMCID: PMC8050927 DOI: 10.1186/s12891-021-04210-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 03/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Bi-modular stems were introduced in primary total hip arthroplasty (THA) to enable better control of the femoral offset, leg length, and hip stability. Despite numerous reports on modular femoral neck fractures, some designs are still marketed worldwide. While the risk factors for the sudden failure are multifactorial and mostly known, the timing of this new THA complication is not predictable by any means. Case presentation In this report, the literature regarding one of the most popular bi-modular stems with specific neck-stem coupling (oval Morse taper) is reviewed and illustrated with a case of bilateral modular neck fracture in a patient with idiopathic aseptic necrosis of femoral heads treated with primary bi-modular THA. Because of bilateral modular femoral neck fracture, which occurred 3 years on the left side and 20 years after implantation on the right side, the patient required a total of 6 revisions and 208 days of hospitalized care. Conclusion To our knowledge, this is the first report of bilateral modular neck fracture in a single patient. Even though the same surgeon performed both operations and used the same neck length and orientation, fractures occurred with a 17-year time difference after implantation. This shows that we cannot predict with certainty when a fracture might occur. Orthopaedic surgeons should use bi-modular stem designs for primary THA very cautiously.
Collapse
|
21
|
Sukopp M, Taylor D, Forst R, Seehaus F. Femoral Stem Fracture in Hip Revision Arthroplasty: A Systematic Literature Review of the Real-World Evidence. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 160:160-171. [PMID: 33851402 PMCID: PMC8967430 DOI: 10.1055/a-1348-2873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background
Total hip arthroplasty (THA) presents as an excellent treatment for the osteoarthritic hip, demonstrating good survival rates. However, aseptic loosening and infection are the main causes of operative revision. The methods used in revision surgery are non-modular or modular THA implants. In addition to the abovementioned revision reasons for THA, this treatment could be associated with the possibility of femoral stem fracture, especially in the modular system. The topic of material failure has been focused on in the public media. The question arises as to how such media reports correlate with the published literature. The observed mentioned number of cases concerning a femoral stem fracture vary between one single case and up to 18.5% within a clinical study, thus presenting an inhomogeneous data situation with a large span. The specific aim of this systematic review is to establish facts and clarify the number of unforeseen events of a femoral stem
fracture based on peer review articles and registry data. This clarification is important to us, as these media reports have led to uncertainty among patients.
Methods
A systematic review was performed in accordance with the PRISMA statement. Peer review articles in English and German, presenting original articles, meta-analyses, or case reports, were searched from the turn of the millennium up to December 2019. Only articles that reported a femoral stem component fracture, with content of clinical data as well as register data, were included. Relevant papers published after the defined research time frame were taken into account within the discussion.
Results
In total, 218 fractures of a femoral stem (141 primary and 77 revision THA) component could be identified within the selected literature. Most cases of a femoral stem fracture occurred in the modular THA implants compared to the non-modular stems. Regarding revision THA, in summary, 77 implants, presenting 23 non-modular and 54 modular implants, failed by means of femoral stem fracture. A review of 11 National Joint Registries shows a revision rate between 0.04 and 0.05% in only 2 registers according to the specific subject of a femoral stem fracture. For the remaining 9 registers, however, detailed information is lacking and only nonspecific information such as a generic “implant failure” or “other reason” (which can cover a multitude of causes) is supplied.
Conclusion
A femoral stem fracture presents a devastating complication for the patient, the surgeon as well as for the manufacturer of the implant. Modular THA implants play an increasingly valuable role concerning restoration of individual anatomy in modern THA revision surgery, especially within complex cases. Regarding revision procedures, data suggests a lower risk of femoral stem fracture for modular implants compared to primary procedures, while the risk of fracture for non-modular implants seems to increase during revision. Ultimately, it cannot be proven whether this is actually applicable, since the absolute number of implanted prosthesis systems is not known. Various implant-, patient-, and surgeon-related factors may lead to these reported femoral stem fractures. However, this systematic review suggests that this is, in general, a rare complication.
Collapse
Affiliation(s)
- Matthias Sukopp
- Institute of Orthopaedic Research and Biomechanics, Centre of Trauma Research, Medical Centre, Ulm University, Ulm, Germany
| | - Dominic Taylor
- Department of Orthopaedic Surgery, Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Raimund Forst
- Department of Orthopaedic Surgery, Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Frank Seehaus
- Department of Orthopaedic Surgery, Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
22
|
Richardson CG, Laende EK, Gross M, Dunbar MJ. Prospective clinical study using radiostereometric analysis (RSA) to evaluate fixation of a modular cemented polished femoral stem. Hip Int 2021; 31:191-195. [PMID: 31615281 DOI: 10.1177/1120700019881429] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND The long-term clinical success of cemented polished tapered femoral components has been demonstrated in prospective as well as registry studies. This stem design type has also been well studied with radiostereometric analysis (RSA) and provides a standard to evaluate alternative designs of polished tapered cemented femoral components. This prospective study evaluates the subsidence of a polished cemented stem with a modular neck design utilising RSA. METHODS 26 patients were prospectively enrolled in the study and 23 were available for RSA analysis at 2 years. RESULTS The average subsidence of the femoral implant was 1.1 mm (SD 0.4 mm) at 2 years post operation. There were no revisions in this group, specifically no failures of the modular stem-neck design as has been seen with other implants. CONCLUSIONS The RSA subsidence pattern at 2 years of this cemented femoral stem is similar to other successful designs with long-term follow-up. The implications over time of stem neck modularity for cemented polished tapered femoral components requires further evaluation.
Collapse
Affiliation(s)
- C Glen Richardson
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Elise K Laende
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Gross
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Michael J Dunbar
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
23
|
Blakeney WG, Lavigne M, Beaulieu Y, Puliero B, Vendittoli PA. Mid-term results of total hip arthroplasty using a novel uncemented short femoral stem with metaphyso-diaphyseal fixation. Hip Int 2021; 31:83-89. [PMID: 31996038 DOI: 10.1177/1120700020903451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Short stems were developed with the promise of providing easier implantation, facilitating revision, reducing thigh pain and proximal stress shielding. The aim of this study is to present the mid-term clinical results of a titanium short stem with modular neck. METHODS This is a prospective case series of 144 THAs performed on a series of 131 patients using the PROFEMUR Preserve Femoral Stem (MicroPort Orthopedics, Arlington, TN, USA). 2 surgeons, operated on the patients using a mini-posterior approach. The primary outcomes evaluated were stem revision for aseptic loosening and all-cause stem revision. Clinical and radiographic outcomes were also assessed. RESULTS Of the 144 THAs, there were 43 males and 101 females, with an average age of 61 (range 22-92) years at surgery. After a mean of 78 (range 53-87) months follow-up, there were 2 (1.5%) femoral implant revisions; 1 for early femoral periprosthetic fracture and 1 for fatigue failure of the modular femoral neck. There were no cases of stem aseptic loosening and radiographic analysis demonstrated no cases of stem migration. The mean UCLA activity, WOMAC and Fogotten Joint scores were respectively 6.1, 10.7 and 86.6. 70% of prosthetic hips were observed as having no restriction and 99.2% of patients were satisfied with their THA. CONCLUSIONS This short modular stem produced satisfactory clinical and radiological results at mid-term, with 98.5% implant survival for any cause of stem revision and no revisions for aseptic loosening. Long-term results are required to further evaluate the stem's promising early results.
Collapse
Affiliation(s)
- William G Blakeney
- Department of Surgery, CIUSSS-de-L'Est-de-L'Ile-de-Montréal, Hospital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Martin Lavigne
- Department of Surgery, CIUSSS-de-L'Est-de-L'Ile-de-Montréal, Hospital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Yann Beaulieu
- Department of Surgery, CIUSSS-de-L'Est-de-L'Ile-de-Montréal, Hospital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Benjamin Puliero
- Department of Surgery, CIUSSS-de-L'Est-de-L'Ile-de-Montréal, Hospital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Pascal-André Vendittoli
- Department of Surgery, CIUSSS-de-L'Est-de-L'Ile-de-Montréal, Hospital Maisonneuve-Rosemont, Montreal, Quebec, Canada.,Department of Surgery, University of Montreal, Canada
| |
Collapse
|
24
|
Kobayashi K, Kidera K, Itose M, Motokawa T, Chiba K, Osaki M. Higher incidence of aseptic loosening caused by a lower canal filling ratio with a modified modular stem in total hip arthroplasty. J Orthop Surg Res 2020; 15:568. [PMID: 33256767 PMCID: PMC7706283 DOI: 10.1186/s13018-020-02101-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/19/2020] [Indexed: 11/14/2022] Open
Abstract
Purpose Although a cementless modular prosthesis has shown reliable results, cases of unstable fixation and revision due to aseptic loosening were observed in our institute. The purpose of this study was to clarify the causes of unstable fixation of the prosthesis. Methods A total of 144 patients (154 hips) who underwent total hip arthroplasty using the modular prosthesis were retrospectively investigated. For the cohort study, 97 patients (104 hips) were included. The femoral component survival rate and sleeve fixation were assessed at a minimum follow-up of 5 years. Patients were divided into 2 groups, including stable and unstable fixation groups, by sleeve fixation. Clinical and radiographic outcomes were compared. Results The Kaplan-Meier survival rate at 9 years was 93% with revision for any reason as the endpoint in study cohort. The reasons for revision were recurrent dislocation (1 hip) and aseptic loosening of the stem (5 hips). A total of 88 hips (84.6%) showed stable fixation, and 16 hips (15.4%) showed unstable fixation at final follow-up. There was no significant difference in clinical outcomes between the 2 groups at final follow-up. The canal flare index was significantly higher, and the canal filling ratio was significantly lower in the unstable fixation group. Conclusion Although the modified modular prosthesis was useful for treating anatomically difficult patients, we need to pay attention to both proximal/distal mismatch of the intramedullary canal and the canal filling ratio to achieve stable fixation and good long-term results.
Collapse
Affiliation(s)
- Kyosuke Kobayashi
- Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan.
| | - Kenichi Kidera
- Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| | - Masaru Itose
- Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| | - Tetsuhiko Motokawa
- Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| | - Ko Chiba
- Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| | - Makoto Osaki
- Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| |
Collapse
|
25
|
Messellek AC, Ould Ouali M, Amrouche A. Adaptive finite element simulation of fretting wear and fatigue in a taper junction of modular hip prosthesis. J Mech Behav Biomed Mater 2020; 111:103993. [DOI: 10.1016/j.jmbbm.2020.103993] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/22/2020] [Accepted: 07/15/2020] [Indexed: 01/20/2023]
|
26
|
Rakow A, Schoon J. Systemic Effects of Metals Released from Arthroplasty Implants – a Brief Summary. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 158:501-507. [DOI: 10.1055/a-1187-1751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AbstractIn recent years, increasing concern has been raised regarding potential systemic toxicity of metals released from arthroplasty implants. A lack of valid metal thresholds for human (organ) toxicity and the prospect of multi-decade survival of modern hip and knee replacements pose special challenges. Indeed, evidence of systemic effects of metals released from such implants is largely missing. Systemic cobalt exposure has repeatedly been associated with cardiotoxic and neurotoxic effects, and also with thyroid dysfunction. The toxic potential of chromium is considered less pronounced. Yet, in arthroplasty there is usually a co-exposure to chromium and cobalt which complicates evaluation of element-specific effects. Toxicity of titanium dioxide nanoparticles has been subject to debate among international regulatory authorities. Their wide use in a variety of products in everyday life, such as toothpaste, cosmetics and food colorants, hampers the assessment of an
arthroplasty-induced systemic titanium exposure. To date there is no clear evidence for systemic complications due to titanium dioxide released from arthroplasty implants. Release of further metals such as tantalum, niobium, nickel, vanadium and zirconium from hip and knee replacement implants has been described occasionally, but systemic effects of respective long-term exposure scenarios are unknown. Generally, the characterization of all released metals regarding their chemical and physical specifications is critical for the evaluation of potential systemic risks. Systematic studies investigating the accumulation of metals relevant in arthroplasty in different organs/organ systems and the biological consequences of such accumulations are urgently needed.
Collapse
Affiliation(s)
- Anastasia Rakow
- Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
| | - Janosch Schoon
- Klinik und Poliklinik für Orthopädie und Orthopädische Chirurgie, Universitätsmedizin Greifswald, Germany
- Julius Wolff Institute, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| |
Collapse
|
27
|
Kheir MM, Drayer NJ, Chen AF. An Update on Cementless Femoral Fixation in Total Hip Arthroplasty. J Bone Joint Surg Am 2020; 102:1646-1661. [PMID: 32740265 DOI: 10.2106/jbjs.19.01397] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Michael M Kheir
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Nicholas J Drayer
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
28
|
Khullar P, Zhu D, Gilbert JL. Fretting corrosion of Si 3 N 4 vs CoCrMo femoral heads on Ti-6Al-V trunnions. J Orthop Res 2020; 38:1617-1626. [PMID: 32249959 DOI: 10.1002/jor.24681] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/07/2020] [Accepted: 03/25/2020] [Indexed: 02/04/2023]
Abstract
Fretting corrosion at the head-neck taper junction was compared between silicon nitride (Si3 N4 ) and commercially available cobalt chrome (CoCrMo) femoral heads on titanium (Ti-6Al-4V) trunnions. An electrochemical setup was used to capture the fretting currents (characterized by oxide abrasion and repassivation) during cyclic loading. Onset load, pull-off force (disassembly load), short term and long term (1 million cycles) fretting currents were used to compare the fretting corrosion performance between the test group (Si3 N4 /Ti-6Al-4V) and the control group (CoCrMo/Ti-6Al-4V). Incremental cyclic fretting corrosion tests showed that the Si3 N4 /Ti-6Al-4V combination had statistically lower (P < .05) average fretting current of 0.189 µA (SD = 0.114 µA) compared to 0.685 µA (SD = 0.630 µA) for CoCrMo/Ti-6Al-4V for cyclic load of 3200 N. Similarly, for the one million cycle fretting corrosion tests, the Si3 N4 /Ti-6Al-4V couples had statistically lower (P < .05) average current (0.048 µA, SD = 0.025 µA) vs CoCrMo/Ti-6Al-4V couples (0.366 µA, SD = 0.143 µA). The Si3 N4 heads also had higher onset loads (P < .05) for fretting (vs CoCrMo, 2200 N vs 1740 N) indicating a difference in surface contact mechanics between the two groups. Scanning electron microscopy with energy dispersive spectroscopy confirmed material transfer from the trunnions to the heads for both groups tested, and from head to trunnion for the CoCrMo heads. Minimal Si3 N4 transfer was noted. The electrochemical, mechanical, and microscopic inspection data supported the hypothesis that Si3 N4 /Ti-6Al-4Vcombination had better fretting corrosion performance compared to CoCrMo/Ti-6Al-4V.
Collapse
Affiliation(s)
- Piyush Khullar
- Clemson-MUSC Bioengineering Program, Charleston, South Carolina.,Department of Bioengineering, Clemson University, Clemson, South Carolina
| | - Dongkai Zhu
- Clemson-MUSC Bioengineering Program, Charleston, South Carolina.,Department of Bioengineering, Clemson University, Clemson, South Carolina
| | - Jeremy L Gilbert
- Clemson-MUSC Bioengineering Program, Charleston, South Carolina.,Department of Bioengineering, Clemson University, Clemson, South Carolina.,Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
29
|
Maniscalco P, Quattrini F, Ciatti C, Ghidoni L, Ghidoni G, Burgio V, Pogliacomi F, Vaienti E, Ceccarelli F. Neck modularity in total hip arthroplasty: a retrospective study of nine hundred twenty-eight titanium neck implants with a maximum follow-up of eighteen years. INTERNATIONAL ORTHOPAEDICS 2020; 44:2261-2266. [PMID: 32601721 DOI: 10.1007/s00264-020-04686-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Neck modularity was introduced to improve total hip arthroplasty (THA) accuracy, but it has been associated with early breakages and corrosion issues. In our hospital, modular necks have been in clinical use since the 1990s. We retrospectively analysed the occurrence of these sequelae in implants placed between January 2000 and December 2014. METHODS Survival data from patients operated on in our hospital were obtained from the regional arthroplasty registry (Registro dell'Impiantologia Protesica Ortopedica, RIPO). The cohort comprised 928 THAs on 908 patients. The average patient age was 67.8 years. Main indications were primary osteoarthritis (71.4%), fracture (9.2%), congenital dysplasia or congenital luxation (7.8%), and idiopathic osteonecrosis (6.4%). All femoral stems were cementless, with 318 anatomically shaped (34.3%), 579 straight (62.4%), and 31 short stems (3.3%). All necks used were made of titanium alloy. The average follow-up time was 9.6 years (range, 4-18 years). RESULTS In total, 66 revisions were reported. The main revision causes were periprosthetic fractures (33.3%), aseptic stem loosening (19.7%), luxation (18.2%), and implant breakage (12.1%). Five modular neck breakages were recorded. The overall survival rate was 87.7% at 17 years. We did not observe any component corrosion. The neck breakage rate was 0.5%, and the luxation rate was 1.3%. CONCLUSIONS Our experience suggests that neck modularity is a safe, effective way to reconstruct the proximal femur in THA patients. We attribute the absence of corrosion to the exclusive use of titanium necks.
Collapse
Affiliation(s)
- Pietro Maniscalco
- Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy
| | | | - Corrado Ciatti
- Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy.
| | - Laura Ghidoni
- Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy
| | - Giuseppe Ghidoni
- Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy
| | - Valeria Burgio
- Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy
| | | | | | | |
Collapse
|
30
|
Frandsen J, Duensing I, Anderson L, Gililland J. Disassociation of a Cold-Welded Bimodular Titanium Femoral Stem by Intraoperative Ice Cooling. Arthroplast Today 2020; 6:457-462. [PMID: 32637516 PMCID: PMC7329910 DOI: 10.1016/j.artd.2020.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/15/2020] [Accepted: 05/21/2020] [Indexed: 11/24/2022] Open
Abstract
Modularity in total hip arthroplasty allows a surgeon to have intraoperative versatility, allowing for fine adjustments of the femoral offset, leg length, and version. However, modularity can be a source of multiple complications. This case report describes a novel intraoperative solution for the problem of cold welding of a neck-stem junction using sterile ice to cryogenically disengage the modular components.
Collapse
Affiliation(s)
- Jeff Frandsen
- Department of Orthopaedics, University of Utah Hospital, Salt Lake City, UT, USA
| | - Ian Duensing
- Department of Orthopaedics, University of Utah Hospital, Salt Lake City, UT, USA
| | - Lucas Anderson
- Department of Orthopaedics, University of Utah Hospital, Salt Lake City, UT, USA
| | - Jeremy Gililland
- Department of Orthopaedics, University of Utah Hospital, Salt Lake City, UT, USA
| |
Collapse
|
31
|
Graulich TJ, Graeff P, Heidenblut T, Krettek C, Liodakis E. Revision of a Fractured Titanium Modular Revision Hip Stem Without Removal of the Well-Fixed Part of the Stem: A New Approach Using a Cemented Tube. Arthroplast Today 2020; 6:363-368. [PMID: 32566718 PMCID: PMC7298535 DOI: 10.1016/j.artd.2020.04.018] [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: 03/01/2020] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022] Open
Abstract
Component fracture is a rare cause for revision in total hip arthroplasty. For a fractured well-fixed long femoral stem, the options are limited. We sought to develop a technique to address this problem with lower morbidity. A newly developed cemented tube was constructed and cemented onto a fractured Revitan revision hip femoral stem to retain the distal well-fixed component. At the 2-year follow-up, the Harris Hip Score, pain level, and radiographic images were analyzed. At the 2-year follow-up, no radiological signs of loosening or failure could be observed. The patient's preoperative Harris Hip Score improved from 42.8 to 97 points. The pain level improved from 7/10 to 0/10. Our case report depicts excellent clinical and radiographic outcomes at 2-year follow-up by a newly developed cemented tube technique. This technique is a potential new option for revision of fractured well-fixed diaphyseal stems without major bone loss. Our successful results suggest this technique is worthy of consideration and further study.
Collapse
Affiliation(s)
| | - Pascal Graeff
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Thorsten Heidenblut
- Institute of Material Science From the Leibniz University of Hannover, Garbsen, Germany
| | | | | |
Collapse
|
32
|
Krueger DR, Guenther KP, Deml MC, Perka C. Mechanical failure of 113 uncemented modular revision femoral components. Bone Joint J 2020; 102-B:573-579. [DOI: 10.1302/0301-620x.102b5.bjj-2019-1333.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aims We evaluated a large database with mechanical failure of a single uncemented modular femoral component, used in revision hip arthroplasty, as the end point and compared them to a control group treated with the same implant. Patient- and implant-specific risk factors for implant failure were analyzed. Methods All cases of a fractured uncemented modular revision femoral component from one manufacturer until April 2017 were identified and the total number of implants sold until April 2017 was used to calculate the fracture rate. The manufacturer provided data on patient demographics, time to failure, and implant details for all notified fractured devices. Patient- and implant-specific risk factors were evaluated using a logistic regression model with multiple imputations and compared to data from a previously published reference group, where no fractures had been observed. The results of a retrieval analysis of the fractured implants, performed by the manufacturer, were available for evaluation. Results There were 113 recorded cases with fracture at the modular junction, resulting in a calculated fracture rate of 0.30% (113/37,600). The fracture rate of the implant without signs of improper use was 0.11% (41/37,600). In 79% (89/113) of cases with a failed implant, either a lateralized (high offset) neck segment, an extralong head, or the combination of both were used. Logistic regression analysis revealed male sex, high body mass index (BMI), straight component design, and small neck segments were significant risk factors for failure. Investigation of the implants (76/113) showed at least one sign of improper use in 72 cases. Conclusion Implant failure at the modular junction is associated with patient- and implant-specific risk factors as well as technical errors during implantation. Whenever possible, the use of short and lateralized neck segments should be avoided with this revision system. Implantation instructions and contraindications need to be adhered to and respected. Cite this article: Bone Joint J 2020;102-B(5):573–579.
Collapse
Affiliation(s)
- D. R. Krueger
- Center for Musculoskeletal Surgery (CMSC), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - K-P. Guenther
- Center for Orthopaedic and Trauma Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M. C. Deml
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - C. Perka
- Center for Musculoskeletal Surgery (CMSC), Charité – Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
33
|
Rickman MS, Lewis PL, Chou DT, Donnelly W, Graves SE, Lorimer M. Risk factors for femoral stem breakage: an analysis of the AOANJRR results. Hip Int 2020; 30:319-326. [PMID: 30945555 DOI: 10.1177/1120700019839206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Breakage of the femoral stem component of a total hip replacement is now uncommon but continues to be seen with certain stem designs and in certain patient groups. Data previously published on this topic has been limited, either gathered from a single surgeon or centre, or included only a single stem design. METHODS We reviewed the data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), identified and analysed 143 stem breakages over a period of 16 years, covering 44 different stem designs. RESULTS Our data confirms previously published findings that risk factors for stem breakage include patient age at implantation of under 70, male gender, as well as the use of exchangeable necks. We found no association with initial diagnosis, or type of acetabular component implanted. We did however also find, excluding exchangeable neck designs, that after 4.5 years a cemented stem had a significantly higher risk of breakage then a cementless stem. DISCUSSION To our knowledge this is the 1st paper to suggest cemented fixation as a specific risk factor for stem breakage. The analysis of rare complications such as stem breakage is only possible through large data collection systems such as the AOANJRR. Whilst there have been recent advances in materials and manufacturing techniques, we recommend that surgeons are aware of all the specific risks when considering implant choices for individual patients.
Collapse
Affiliation(s)
- Mark S Rickman
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Orthopaedics and Trauma, University of Adelaide, Australia
| | - Peter L Lewis
- Wakefield Orthopaedic Clinic, Adelaide, Australia.,AOA (Australian Orthopaedic Association) National Joint Replacement Registry, SAHMRI (South Australia Health and Research Institute), Adelaide, Australia
| | - Daud Ts Chou
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Orthopaedics and Trauma, University of Adelaide, Australia
| | | | - Stephen E Graves
- AOA (Australian Orthopaedic Association) National Joint Replacement Registry, SAHMRI (South Australia Health and Research Institute), Adelaide, Australia
| | - Michelle Lorimer
- AOA (Australian Orthopaedic Association) National Joint Replacement Registry, SAHMRI (South Australia Health and Research Institute), Adelaide, Australia
| |
Collapse
|
34
|
Grupp TM, Baxmann M, Jansson V, Windhagen H, Heller KD, Morlock MM, Knaebel HP. How to proceed with asymptomatic modular dual taper hip stems in the case of acetabular revision. MATERIALS 2020; 13:ma13051098. [PMID: 32121627 PMCID: PMC7084958 DOI: 10.3390/ma13051098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 12/15/2022]
Abstract
How to proceed with a clinically asymptomatic modular Metha® Ti alloy stem with dual taper CoCr neck adapter in case of acetabular revision? To systematically answer this question the status of research and appropriate diagnostic methods in context to clinically symptomatic and asymptomatic dual taper stem-neck couplings has been evaluated based on a systematic literature review. A retrieval analysis of thirteen Metha® modular dual taper CoCr/Ti alloy hip stems has been performed and a rational decision making model as basis for a clinical recommendation was developed. From our observations we propose that in cases of acetabular revision, that for patients with a serum cobalt level of > 4 µg/L and a Co/Cr ratio > 3.6, the revision of the modular dual taper stem may be considered. Prior to acetabular revision surgery a systematic diagnostic evaluation should be executed, using specific tests such as serum metal (Co, Cr) ion analysis, plain antero-posterior and lateral radiographs and cross-sectional imaging modalities (Metal Artefact Reduction Sequence Magnetic Resonance Imaging). For an asymptomatic Metha® dual taper Ti alloy/CoCr stem-neck coupling at the stage of acetabular revision careful clinical decision making according to the proposed model should be followed and overreliance on any single examination should be avoided, considering the complete individual differential diagnosis and patient situation.
Collapse
Affiliation(s)
- Thomas M. Grupp
- Aesculap AG Research & Development, 78532 Tuttlingen, Germany;
- Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern Ludwig Maximilians University Munich, 81377 Munich, Germany;
- Correspondence: ; Tel.: +49-7461-95-2667; Fax: +49-7461-95-382667
| | - Marc Baxmann
- Aesculap AG Research & Development, 78532 Tuttlingen, Germany;
| | - Volkmar Jansson
- Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern Ludwig Maximilians University Munich, 81377 Munich, Germany;
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany;
| | - Karl-Dieter Heller
- Department of Orthopaedic Surgery, Herzogin-Elisabeth-Hospital, 38124 Braunschweig, Germany;
| | - Michael M. Morlock
- Institute of Biomechanics, TUHH Hamburg University of Technology, 21073 Hamburg, Germany;
| | | |
Collapse
|
35
|
Mertl P, Dehl M. Femoral stem modularity. Orthop Traumatol Surg Res 2020; 106:S35-S42. [PMID: 31624033 DOI: 10.1016/j.otsr.2019.05.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 02/02/2023]
Abstract
Femoral stem modularity in hip replacement was first developed to connect a ceramic head to the stem, then extended to metal heads using the Morse taper principle. Is it a good thing, or a necessary evil? It contributes to improving lower limb length and lateralization setting, at the cost of fairly rare complications such as dissociation and fretting corrosion, which can exceptionally lead to ARMD (Adverse Reaction to Metal Debris). Modular necks were later recommended, with a double Morse taper: cylindrical for the head junction, and more or less flattened for the stem. Is this one modularity too far? Dual modularity in theory perfectly reproduces the biomechanical parameters of the hip, but is unfortunately associated with fractures and severe corrosion, leading to ARMD and pseudotumor, especially in Cr-Co necks. Moreover, it provides no functional advantage, and no longer has a role outside dysplasia and other femoral deformities. Metaphyseal-diaphyseal modularity is not widespread in primary implants, and is it really necessary? Only one model has been widely studied: S-Rom™ (Depuy®). It features a metaphyseal sleeve adapting to the anatomy of the proximal femur, with a stem fitted via an inverse Morse taper. Its only interest is in case of congenital dislocation; like all metal connections, it incurs a risk of fracture and corrosion. On the other hand, modularity is widely employed in revision implants. Does it really help these procedures? The connection between a proximal femoral component of variable geometry and a diaphyseal stem with press-fit distal fixation provides a real solution to problems of length, lateralization and anteversion. Early models encountered high rates of fracture, but current implants and rigorous surgical technique have reduced this risk. Corrosion is a less serious problem, as the Morse taper undergoes only axial stress, without the friction undergone by other models subject to varus stress.
Collapse
Affiliation(s)
- Patrice Mertl
- Service d'orthopédie-traumatologie, CHU d'Amiens, Site Sud, 80054 Amiens Cedex, France.
| | - Massinissa Dehl
- Service d'orthopédie-traumatologie, CHU d'Amiens, Site Sud, 80054 Amiens Cedex, France
| |
Collapse
|
36
|
Lützner J, Günther KP, Postler A, Morlock M. Metal Ion Release after Hip and Knee Arthroplasty - Causes, Biological Effects and Diagnostics. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:369-382. [PMID: 31820432 DOI: 10.1055/a-0929-8121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
All metal implants in human bodies corrode which results in metal ions release. This is not necessarily a problem and represents for most patients no hazard. However, if a critical metal ion concentration is exceeded, local or rarely systemic problems can occur. This article summarizes the mechanisms of metal ion release and its clinical consequences. Several situations can result in increased metal ion release: metal-on-metal hip arthroplasties with increased wear, increased micromotion at taper interfaces, direct metal-metal contact (polyethylene wear, impingement), erroneously used metal heads after ceramic head fracture. Possible problems are in most cases located close to the concerned joint. Furthermore, there are reports about toxic damage to several organs. Most of these reports refer to erroneously used metal heads in revisions after a broken ceramic head. There is currently no evidence of carcinogenic or teratogenic effects of implants but data is not sufficient to exclude possible effects. Cobalt and chromium blood levels (favorably in whole blood) should be measured in patients with suspected elevated metal ions. According to current knowledge levels below 2 µg/l seem to be uncritical, levels between 2 and 7 µg/l are considered borderline with unknown biological consequences and levels above 7 µg/l indicate a local problem which should be further diagnosed. Metal ion levels always need to be interpreted together with clinical symptoms and imaging results.
Collapse
Affiliation(s)
- Jörg Lützner
- University Center of Orthopaedics and Trauma Surgery, TU Dresden
| | | | - Anne Postler
- University Center of Orthopaedics and Trauma Surgery, TU Dresden
| | | |
Collapse
|
37
|
Murena L, Maritan G, Concina C, Scamacca V, Ratti C, Canton G. Fracture of Cobalt-Crome Modular Neck in Total Hip Arthroplasty. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:187-191. [PMID: 31821307 PMCID: PMC7233721 DOI: 10.23750/abm.v90i12-s.8941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 10/25/2019] [Indexed: 02/08/2023]
Abstract
Despite the advantages of modular total hip arthroplasty in terms of neck version, offset and length precise reproduction, titanium necks breakage became a concern. Consequently, titanium has been replaced by cobalt-chrome (Co-Cr). However, four cases of Co-Cr modular neck breakage have been reported in the literature. In the present paper, two cases of Co-Cr modular neck fractures are described together with a literature review. The aim of this work is to discuss the risk factors and characteristics of this rare complication. We described two cases of fracture of long varus Co-Cr modular femoral neck connected with cementless press-fit stem. Some risk factors, such as long varus type of modular neck, overweight and/or high demanding physical activity, might have contributed to implant failure.
Collapse
Affiliation(s)
- Luigi Murena
- Orthopaedics and Traumatology Unit, Cattinara Hospital - ASUITS, Strada di Fiume 447, 34149 Trieste (Italy).
| | | | | | | | | | | |
Collapse
|
38
|
Crackau M, Märtens N, Harnisch K, Berth A, Döring J, Lohmann CH, Halle T, Bertrand J. In vivo corrosion and damages in modular shoulder prostheses. J Biomed Mater Res B Appl Biomater 2019; 108:1764-1778. [PMID: 31763747 DOI: 10.1002/jbm.b.34519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/30/2019] [Accepted: 11/04/2019] [Indexed: 11/08/2022]
Abstract
Wear and corrosion at taper junctions of orthopaedic endoprostheses remain of great concern and are associated with adverse clinical reactions. Whereas tribocorrosion of hip tapers was extensively investigated, there is only little knowledge regarding the clinical performance of modular total shoulder prostheses. This retrieval study evaluated 35 modular taper junctions of anatomical shoulder explants using stereomicroscopy, confocal microscopy, as well as optical and scanning electron microscopy to determine the damage modes as well as the effects of taper topography and alloy microstructure. Among all humeral head tapers, 89% exhibited material degradation. Different overlapping wear mechanisms were identified such as plastic deformation, adhesive material transfer, microploughing, and fretting damage. Only CoCrMo cast alloy heads showed a susceptibility to electrochemically dominated fretting in comparison to CoCrMo wrought alloy. Moreover, corundum blasted stem tapers show a significantly increased incidence rate for microploughing. To date, this is the most comprehensive study on the damage types of modular taper junctions of anatomical shoulder arthroplasty proving the existence of fretting even on less weight-bearing implants. This study revealed critical fretting factors, such as the surface finish and the alloy type that are essential for the development of countermeasures that avoid any taper corrosion.
Collapse
Affiliation(s)
- Maria Crackau
- Institute of Materials and Joining Technology, Otto-von-Guericke University, Magdeburg, Germany.,Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Nicole Märtens
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Karsten Harnisch
- Institute of Materials and Joining Technology, Otto-von-Guericke University, Magdeburg, Germany
| | - Alexander Berth
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Joachim Döring
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Christoph H Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Thorsten Halle
- Institute of Materials and Joining Technology, Otto-von-Guericke University, Magdeburg, Germany
| | - Jessica Bertrand
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| |
Collapse
|
39
|
Wawrose RA, Urish KL. Diagnosis and Management of Adverse Reactions to Metal Debris. OPERATIVE TECHNIQUES IN ORTHOPAEDICS 2019; 29:100732. [PMID: 32296268 PMCID: PMC7158878 DOI: 10.1016/j.oto.2019.100732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Modern total hip arthroplasty implants have incorporated modularity into their designs, providing the benefits of intraoperative flexibility and the ability to exchange the femoral heads in the future if necessary. However, this feature has unfortunately predisposed patients to the effects of corrosion, potentially resulting in adverse local tissue reactions (ALTR) and even systemic effects. A thorough understanding of the science of corrosion is important for the treating surgeon so that they can understand the underlying pathology, quickly diagnose the condition of ALTR, and risk stratify their patients to determine the best method of treatment. Revision surgery is not always necessary in cases of trunnionosis or ALTR, but the results of revision surgery are generally favorable.
Collapse
Affiliation(s)
- Richard A. Wawrose
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, 3471 Fifth Ave., Suite 1010, Pittsburgh, PA 15213
| | - Kenneth L. Urish
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, 3471 Fifth Ave., Suite 1010, Pittsburgh, PA 15213
| |
Collapse
|
40
|
Urish KL, Giori NJ, Lemons JE, Mihalko WM, Hallab N. Trunnion Corrosion in Total Hip Arthroplasty-Basic Concepts. Orthop Clin North Am 2019; 50:281-288. [PMID: 31084829 PMCID: PMC6521866 DOI: 10.1016/j.ocl.2019.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There has been increased interest in the role of corrosion in early implant failures and adverse local tissue reaction in total hip arthroplasty. We review the relationship between the different types of corrosion in orthopaedic surgery including uniform, pitting, crevice, and fretting or mechanically assisted crevice corrosion (MACC). Passive layer dynamics serves a critical role in each of these processes. The femoral head-neck trunnion creates an optimal environment for corrosion to occur because of the limited fluid diffusion, acidic environment, and increased bending moment.
Collapse
Affiliation(s)
- Kenneth L. Urish
- Corresponding Author: Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA. .
| | - Nicholas John Giori
- VA Palo Alto Health Care System, Palo Alto, CA and Department of Orthopaedic Surgery, Stanford University, Stanford, CA, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063-6342
| | - Jack E. Lemons
- Department of Orthopaedic Surgery, University of Alabama at Birmingham. Birmingham, AL, 1313 13th Street South, Birmingham, AL 35205-5327
| | - William M. Mihalko
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN 1211 Union Avenue, Suite 510, Memphis TN 38104
| | - Nadim Hallab
- Department of Orthopaedic Surgery, Rush University, Chicago, IL 1653 W. Congress Parkway, Chicago, IL 60612
| |
Collapse
|
41
|
Kovač S, Mavčič B, Kotnik M, Levašič V, Sirše M, Fokter SK. What Factors Are Associated With Neck Fracture in One Commonly Used Bimodular THA Design? A Multicenter, Nationwide Study in Slovenia. Clin Orthop Relat Res 2019; 477:1324-1332. [PMID: 31136429 PMCID: PMC6554145 DOI: 10.1097/corr.0000000000000646] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoral stems with bimodular (head-neck as well as neck-body) junctions were designed to help surgeons address patients' hip anatomy individually. However, arthroplasty registers have reported higher revision rates in stems with bimodular junctions than in stems with modularity limited to the head-neck trunnion. However, to our knowledge, no epidemiologic study has identified patient-specific risk factors for modular femoral neck fractures, and some stems using these designs still are produced and marketed. QUESTIONS/PURPOSES The purposes of this study were (1) to establish the survival rate free from aseptic loosening of one widely used bimodular THA design; (2) to define the proportion of patients who experienced a fracture of the stem's modular femoral neck; and (3) to determine factors associated with neck fracture. METHODS In this retrospective, nationwide, multicenter study, we reviewed 2767 bimodular Profemur® Z stems from four hospitals in Slovenia with a mean followup of 8 years (range, 3 days to 15 years). Between 2002 and 2015, the four participating hospitals performed 26,132 primary THAs; this implant was used in 2767 of them (11%). The general indications for using this implant were primary osteoarthritis (OA) in 2198 (79%) hips and other indications in 569 (21%) hips. We followed patients from the date of the index operation to the date of death, date of revision, or the end of followup on March 1, 2018. We believe that all revisions would be captured in our sample, except for patients who may have emigrated outside the country, but the proportion of people immigrating to Slovenia is higher than the proportion of those emigrating from it; however, no formal accounting for loss to followup is possible in a study of this design. There were 1438 (52%) stems implanted in female and 1329 (48%) in male patients, respectively. A titanium alloy neck was used in 2489 hips (90%) and a cobalt-chromium neck in 278 (10%) hips. The mean body mass index (BMI) at the time of operation was 29 kg/m (SD ± 5 kg/m). We used Kaplan-Meier analysis to establish survival rates, and we performed a chart review to determine the proportion of patients who experienced femoral neck fractures. A binary logistic regression model that controlled for the potential confounding variables of age, sex, BMI, time since implantation, type of bearing, diagnosis, hospital, neck length, and neck material was used to analyze neck fractures. RESULTS There were 55 (2%) aseptic stem revisions. Survival rate free from aseptic loosening at 12 years was 97% (95% confidence interval [CI] ± 1%). Fracture of the modular neck occurred in 23 patients (0.83%) with a mean BMI of 29 kg/m (SD ± 4 kg/m.) Twenty patients with neck fractures were males and 19 of 23 fractured necks were long. Time since implantation (odds ratio [OR], 0.55; 95% CI 0.46-0.66; p < 0.001), a long neck (OR, 6.77; 95% CI, 2.1-22.2; p = 0.002), a cobalt-chromium alloy neck (OR, 5.7; 95% CI, 1.6-21.1; p = 0.008), younger age (OR, 0.91; 95% CI, 0.86-0.96; p < 0.001), and male sex (OR, 3.98; 95% CI, 1.04-14.55; p = 0.043) were factors associated with neck fracture. CONCLUSIONS The loosening and neck fracture rates of the Profemur® Z stem were lower than in some of previously published series. However, the use of modular femoral necks in primary THA increases the risk for neck fracture, particularly in young male patients with cobalt-chromium long femoral necks. The bimodular stem we analyzed fractured unacceptably often, especially in younger male patients. For most patients, the risks of using this device outweigh the benefits, and several dozen patients had revisions and complications they would not have had if a different stem had been used. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Simon Kovač
- S. Kovač, V. Levašič, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia B. Mavčič, Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia M. Kotnik, Department of Orthopaedics, Celje General Hospital, Celje, Slovenia M. Sirše, S. K. Fokter, Department of Orthopaedics, University Medical Centre Maribor, Maribor, Slovenia
| | | | | | | | | | | |
Collapse
|
42
|
Snethen K, Hernandez J, Harman M. The effect of manufacturing tolerances on the mechanical environment of taper junctions in modular TKR. J Mech Behav Biomed Mater 2019; 97:49-57. [PMID: 31100485 DOI: 10.1016/j.jmbbm.2019.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/19/2018] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
Abstract
Taper design is known to influence corrosive behavior in taper junctions used in modular orthopaedic devices. Manufacturing tolerance of bore-cone tapers is a critical design parameter due to the effect on taper fit, but the effect of variations in manufacturing tolerance on the mechanics of taper junctions has not been well characterized, particularly in modular total knee replacement (TKR). The purpose of this study was to investigate the effect of manufacturing tolerance on stress and micromotion of modular TKR taper junctions. A 3D finite element (FE) model of a modular TKR taper junction was developed and assigned elastoplastic material properties. Model taper geometry was varied by perturbing the angle mismatch by 0.05° between ±0.25° and represented expected variation in manufacturing tolerance. Stress and micromotion were calculated during dynamic FE simulations for each taper junction geometry under varying activity loads and material combinations. Although an increase in angle mismatch generally resulted in higher stress and micromotion, plastic material behavior disrupted this trend for larger angle mismatches. Model predictions corresponded with corrosion behavior evident in vitro. If the FE results obtained here apply in vivo, the absence of elastoplastic material properties in a taper model may grossly overestimate the micromotion and underestimate corrosion behavior and ion release. It is recommended that manufacturing tolerances of bore-cone tapers in modular TKR designs should produce angle mismatches within 0.1° at the taper junction.
Collapse
Affiliation(s)
- Kyle Snethen
- Bioengineering Department, Clemson University, Clemson, USA
| | | | - Melinda Harman
- Bioengineering Department, Clemson University, Clemson, USA.
| |
Collapse
|
43
|
Sonntag R, Gibmeier J, Pulvermacher S, Mueller U, Eckert J, Braun S, Reichkendler M, Kretzer JP. Electrocautery Damage Can Reduce Implant Fatigue Strength: Cases and in Vitro Investigation. J Bone Joint Surg Am 2019; 101:868-878. [PMID: 31094978 DOI: 10.2106/jbjs.18.00259] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The risk of femoral stem fracture after total hip replacement is low and can often be associated with a specific implant system or other factors that may reduce the fatigue strength. Additionally, damage to a metal component during revision surgery by an electrocautery device may further affect the fatigue behavior. METHODS Two clinical cases of stem failure after revision of fractured ceramic components are presented; the retrieved components were analyzed for the cause of failure. In vitro cyclic load-to-failure testing of titanium alloy femoral stems after electrocautery application at 2 different locations (at the base and about midway on the femoral neck) was performed using a stepwise increase in load until implant fracture occurred. In addition, a detailed characterization of the local material structure around the electrocautery marks was performed. RESULTS Superficial discoloration and melting marks were found on the retrieved components, including at the location of crack initiation in the anterolateral region, which may have reduced the fatigue strength of the material. In addition, elemental analysis indicated material transfer from the electrocautery tip. Damage to the surface by the electrocautery device significantly reduced the in vitro load to failure by up to 47% compared with that of undamaged femoral neck specimens. Material analysis revealed a relevant modification in microstructure, with an extension of approximately 2.7 mm and a depth of 550 µm, which could be divided in 3 structural zones. CONCLUSIONS Intraoperative electrocautery device contact with the implant during surgical revision of a total hip replacement cannot always be avoided. However, on the basis of our findings, the risk of implant failure is increased due to a change in microstructure and a potential reduction of the implant's fatigue strength. Surgeons and manufacturers of electrocautery devices should be aware of this concern. CLINICAL RELEVANCE During revision surgery, contact between an electrocautery device and the femoral component should be avoided to reduce the chance of subsequent femoral neck fracture.
Collapse
Affiliation(s)
- Robert Sonntag
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jens Gibmeier
- Institute of Applied Materials, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Samuel Pulvermacher
- Institute of Applied Materials, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Ulrike Mueller
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Eckert
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Steffen Braun
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Reichkendler
- Department of Orthopedic and Trauma Surgery, District Hospital Schwaz, Schwaz, Austria
| | - J Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
44
|
Design, Material, and Seating Load Effects on In Vitro Fretting Corrosion Performance of Modular Head-Neck Tapers. J Arthroplasty 2019; 34:991-1002. [PMID: 30827717 DOI: 10.1016/j.arth.2019.01.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/03/2019] [Accepted: 01/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The short-term corrosion and micromechanical behavior of 32 unique head-neck taper design/material/assembly conditions was tested using an incremental cyclic fretting corrosion (ICFC) test method previously developed. METHODS Seven materials, design, and simulated surgical parameters were evaluated, each being assigned 2 conditions for testing, using a 27-2 (7 factor, quarter factorial) design of experiments test matrix. The factors explored were (1) seating load, (2) head-neck offset, (3) material combination, (4) taper diameter, (5) taper roughness, (6) angular mismatch/engagement, and (7) taper length. Each sample underwent assembly, ICFC testing, pull off. RESULTS Low seating load and high head offset correlated with increased fretting corrosion (P < .05). High head offset also contributed to a lower onset load for fretting current and higher micromotion (P < .05). Head subsidence measured over the ICFC test for samples seated at 100 N was significantly higher than samples seated at 4000 N. Micromotion for 12-mm head offsets was statistically higher than samples with a 1.5-mm head offset. A number of interactive effects were observed. For example, samples seated at 4000 N were less sensitive to head offset than samples seated at 100 N in terms of the resulting fretting current. CONCLUSION Taper locking position, material combination, taper engagement length, taper roughness, and taper dimensions all had weak or no correlation with fretting current and taper micromotion. This test method and experimental design is a versatile means of assessing potential new taper designs in the future.
Collapse
|
45
|
Aboltins CA, Antoci V, Bhattacharyya S, Cross M, Ducheyne P, Freiberg AA, Hailer N, Kay P, Ketonis C, Klement MR, Köse N, Lee M, Mitchell P, Nandi S, Palacio JC, Perry K, Prieto H, Shahi A, Trebše R, Turner D, Wu CT, Yazdi H. Hip and Knee Section, Prevention, Prosthesis Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S309-S320. [PMID: 30348551 DOI: 10.1016/j.arth.2018.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
|
46
|
Regis D, Christodoulidis A, Magnan B, Sandri A. Late fracture of an old-generation modular neck in a titanium alloy femoral stem of a cementless total hip arthroplasty. J Clin Orthop Trauma 2019; 10:1008-1011. [PMID: 31528086 PMCID: PMC6739490 DOI: 10.1016/j.jcot.2018.06.008] [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: 03/21/2018] [Revised: 05/19/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022] Open
Abstract
Neck-stem modularity gained recent popularity in hip arthroplasty for clinical advantages, and few complications have been reported. We describe an unusual two-stage failure of the bimodular neck of a cementless forged titanium alloy stem implanted 12 years before. The retrieved neck was forwarded to the manufacturer for metallurgic evaluation and failure analysis. Lengthening and bending of the superolateral aspect of the neck and double depression of the medial part prove that the prosthetic neck underwent a medial displacement and a varus rotation. The crack initiated from the superolateral corner of the fracture section, and the neck probably underwent two subsequent unstable configurations. The first horizontal part of the fracture occurred in the external surface as a result of physiological load carried on abnormal conditions of frictions. Due to increased oscillations, the end of the fracture section knocked against the inner aspect of the proximal hole of the stem, preventing further valgus displacement of the neck, which was moved forward. Consequently, the neck achieved a second unstable configuration, and the fracture propagated in the weaker direction creating a bent track. Finally, the neck broke unexpectedly as a result of the traumatic event. An incorrect placement into the femoral component during surgery was the initiation of the failure of the bimodular neck. The transitory but repeated interface motion between the neck and the stem induced a local surface irregularity acting as a starting point for crack propagation of fatigue fracture. Final failure followed a direct trauma.
Collapse
Affiliation(s)
- Dario Regis
- Corresponding author at: UOC Ortopedia e Traumatologia B - Polo Chirurgico P Confortini, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A Stefani 1, 37126 Verona, Italy.
| | | | | | | |
Collapse
|
47
|
Zajc J, Predan J, Gubeljak N, Moličnik A, Fokter SK. Modular femoral neck failure after revision of a total hip arthroplasty: a finite element analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:717-723. [PMID: 30317469 DOI: 10.1007/s00590-018-2314-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/07/2018] [Indexed: 12/14/2022]
Abstract
The authors report on a case of modular femoral neck fracture which appeared 21 months after revision of acetabular component. The revision surgery was performed 8 years after the primary total hip arthroplasty due to aseptic loosening of the acetabular component. During acetabular revision, the primary implanted short (S, - 3.5 mm) femoral head was also exchanged with extra-long (XL, + 7.0 mm) femoral head fitting the modular femoral neck with a longer lever arm. Numerical analysis has shown that this has resulted in a 19.9% increase in tensile stress at the neck-stem coupling during normal walking cycle. This could result in microcrack initiation and propagation and finally lead to modular neck failure of the otherwise well-fixed stem. Surgeons should avoid excessive loading of the exchangeable neck (dual-modular) femoral stem designs as the stem-neck couplings are subject to corrosion and are not as reliable as monoblock stems.
Collapse
Affiliation(s)
- Jan Zajc
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Jožef Predan
- Faculty of Mechanical Engineering, University of Maribor, Maribor, Slovenia
| | - Nenad Gubeljak
- Faculty of Mechanical Engineering, University of Maribor, Maribor, Slovenia
| | - Andrej Moličnik
- Department for Orthopaedic Surgery, University Medical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Samo K Fokter
- Department for Orthopaedic Surgery, University Medical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia.
| |
Collapse
|
48
|
Kiran M, Makridis KG, Armstrong C, Kapoor B, Kumar G, Peter V. Withdrawn: A Randomized Controlled Trial Comparing Modular and Nonmodular Neck Versions of a Titanium Stem. J Arthroplasty 2018:S0883-5403(18)30820-9. [PMID: 30316623 DOI: 10.1016/j.arth.2018.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/10/2018] [Accepted: 09/14/2018] [Indexed: 02/01/2023] Open
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
Collapse
Affiliation(s)
- Manish Kiran
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Konstantinos G Makridis
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Catherine Armstrong
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Birender Kapoor
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Gunasekaran Kumar
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Viju Peter
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| |
Collapse
|
49
|
Lanting B, Naudie DDR, McCalden RW. Clinical Impact of Trunnion Wear After Total Hip Arthroplasty. JBJS Rev 2018; 4:01874474-201608000-00003. [PMID: 27603271 DOI: 10.2106/jbjs.rvw.15.00096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Trunnionosis, characterized by corrosion and fretting of the taper, is a well-known entity commonly demonstrated in retrieval specimens. While there have been a number of recent reports regarding the potential for adverse local tissue reactions related to trunnionosis, it remains a relatively infrequent cause for failure of total hip replacement implants. A number of factors, including both biomechanical and bioelectrochemical factors, have a known impact on the development and severity of trunnionosis. Furthermore, specific implant design and material-related factors have been shown to influence the risk of trunnionosis leading to adverse local tissue reactions. Retention of a well-fixed femoral stem, in spite of corrosion of the male taper junction, is acceptable in the majority of cases. A ceramic head, often in combination with a titanium adaptor sleeve, is the most common replacement reported in the current literature to treat trunnionosis. In patients with modular-neck total hip replacements, revision of the femoral stem is likely required if corrosion at the modular neck-stem junction is encountered.
Collapse
Affiliation(s)
- Brent Lanting
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada.,Joint Replacement Institute, London Health Sciences Center, University Hospital, London, Ontario, Canada
| | - Douglas D R Naudie
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada.,Joint Replacement Institute, London Health Sciences Center, University Hospital, London, Ontario, Canada
| | - Richard W McCalden
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada.,Joint Replacement Institute, London Health Sciences Center, University Hospital, London, Ontario, Canada
| |
Collapse
|
50
|
Papaioannou I, Repantis T, Baikousis A, Korovessis P. Late Onset Disassembly of a Modular Neck-stem Component after Cementless Hip Replacement without Dislocation: A Case Report and Review of Literatures. Hip Pelvis 2018; 30:190-195. [PMID: 30202754 PMCID: PMC6123507 DOI: 10.5371/hp.2018.30.3.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/28/2018] [Accepted: 07/06/2018] [Indexed: 11/24/2022] Open
Abstract
Modular femoral prostheses are characterized by a second neck-stem junction. This modularity provides many clinical benefits including hip offset restoration, intraoperative leg length and anteversion adjustment. Although, this extra junction in modular femoral prostheses can contribute to catastrophic consequences like fracture, cold welding, corrosion and fretting of the modularity. However, only few complications related to the modularity itself have been reported in the literature. We report a unique case of neck-stem component dissociation without dislocation of the R-120PC™ Modular Stem (DJO Surgical). Our 71-year-old obese female patient underwent cementless hip replacement 5 years ago. Following radiographic confirmation of neck-stem dissociation open reduction was performed and wiring fixation was applied to secure the neck to the stem. After reduction and fixation, hip joint was stable, and our patient returned to her daily routine 2.5 months postoperatively. The last follow up was at 12 months after surgery with excellent radiographic and clinical evaluation.
Collapse
Affiliation(s)
| | - Thomas Repantis
- Department of Orthopedics, General Hospital of Patras, Patras, Greece
| | - Andreas Baikousis
- Department of Orthopedics, General Hospital of Patras, Patras, Greece
| | | |
Collapse
|