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Uzoigwe CE, Watts AT, Briggs P, Symes T. Periprosthetic Femoral Fractures-Beyond B2. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202408000-00003. [PMID: 39110721 PMCID: PMC11309721 DOI: 10.5435/jaaosglobal-d-23-00135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 04/11/2024] [Accepted: 05/07/2024] [Indexed: 08/10/2024]
Abstract
The proliferation of hip arthroplasty has seen concomitant increases in periprosthetic femoral fractures (PFFs). The most common pattern involves fracture at the level of a loose prosthesis (B2). B2 PFFs have a unique mechanopathogenesis linked to the tendency of polished taper-slip cemented stems to subside in the cement. Such stems carry a much higher PFF risk than other cemented designs. Mega-data, consistent across national registries, suggest that increasing application of the taper-slip principle has resulted in the emergence of highly polished, very low friction cemented prostheses. These have the propensity to migrate within the cement, increasing B2 PFF risk. This would explain the strong association between cobalt-chromium stems and PFF. Is PFF the mode of failure of polished taper-slip stems rather than aseptic loosening? Established wisdom teaches that B2 PFFs should be managed with revision surgery. There is a large body of new evidence that, in certain instances, fixation results in outcomes at least equivalent to revision arthroplasty, with shorter surgical time, decreased transfusion requirements, and lower dislocation risk. This is so in B2 PFFs around cemented polished taper-slip stems with an intact bone-cement interface. We outline advances in understanding of B2 PFF with special reference to mechanopathogenesis and indications for fixation.
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Affiliation(s)
- Chika Edward Uzoigwe
- From the Harcourt House Sheffield, UK (Mr. Uzoigwe); Hull Royal Infirmary, Hull, UK (Mr. Watts, Mr. Briggs, and Mr. Symes)
| | - Arun Thor Watts
- From the Harcourt House Sheffield, UK (Mr. Uzoigwe); Hull Royal Infirmary, Hull, UK (Mr. Watts, Mr. Briggs, and Mr. Symes)
| | - Praise Briggs
- From the Harcourt House Sheffield, UK (Mr. Uzoigwe); Hull Royal Infirmary, Hull, UK (Mr. Watts, Mr. Briggs, and Mr. Symes)
| | - Tom Symes
- From the Harcourt House Sheffield, UK (Mr. Uzoigwe); Hull Royal Infirmary, Hull, UK (Mr. Watts, Mr. Briggs, and Mr. Symes)
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Sakurai T, Fujita H, Iwase T, Sasaki K, Katayama N, Otsuka H. Multi-center study of use of the Exeter stem in Japan: a 10-year follow-up report. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04001-w. [PMID: 38822154 DOI: 10.1007/s00590-024-04001-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/09/2024] [Indexed: 06/02/2024]
Abstract
PURPOSE Since the introduction of the Exeter stem for clinical use in Japan in 1996, the number of stems used has continued to rise owing to its favorable results. We investigated the outcomes of patients who had previously undergone total hip arthroplasty with the Exeter stem in Japan with a 10-year + follow-up period. METHODS This retrospective cohort study used clinical and radiographic data of 682 cases of primary total hip arthroplasty performed using the Exeter stem. RESULTS The mean postoperative follow-up period was 13.3 years. Femoral-side revision was required in 14 hips, with no cases of aseptic stem loosening-associated revision observed. Kaplan-Meier survival analysis predicted 97.3% 15-year survival when revision for any reason was used as the endpoint. CONCLUSION The obtained findings suggested the excellent long-term stability of the Exeter stem for primary total hip arthroplasty in Japan.
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Affiliation(s)
- Tatsuro Sakurai
- Department of Orthopedic Surgery, Nagareyama Central Hospital, 2-243-3 Higashihatsuishi, Nagareyama-shi, Chiba, 270-0114, Japan.
| | - Hiroshi Fujita
- Center for Hip Arthroplasty, Senshunkai Hospital, Nagaokakyo-shi, Kyoto, 617-0826, Japan
| | - Toshiki Iwase
- Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Shizuoka, 432-8580, Japan
| | - Kan Sasaki
- Department of Orthopedic Surgery, Yamagata Saisei Hospital, Okimachi, Yamagata, 990-8545, Japan
| | - Naoyuki Katayama
- Department of Orthopedic Surgery, Hokkaido Orthopedic Memorial Hospital, Sapporo, Hokkaido, 062-0937, Japan
| | - Hiromi Otsuka
- Department of Orthopedic Surgery, School of Medicine, Aichi Medical University, Nagakute-shi, Aichi, 480-1195, Japan
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Yagura T, Oe K, Kobayasi F, Sogawa S, Nakamura T, Iida H, Saito T. Experimental periprosthetic fractures with collarless polished tapered cemented stems. INTERNATIONAL ORTHOPAEDICS 2024; 48:1171-1178. [PMID: 38443715 DOI: 10.1007/s00264-024-06136-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE After cemented total hip arthroplasty, the risk of periprosthetic fracture (PPF) of taper-slip stems is higher than that of composite-beam stems. We aimed to assess the conditions resulting in PPFs of taper-slip stems using a falling weight. METHODS Taper-slip stems were fixed to five types of simulated bone models using bone cement, and the fractures were evaluated by dropping stainless-steel weights from a predetermined height onto the heads. The periprosthetic fracture height in 50% of the bone models (PPFH50) was calculated using the staircase method. RESULTS For the fixation with 0° of flexion, the values for PPFH50 were 61 ± 11, 60 ± 13, above 110, 108 ± 49, and 78 ± 12 cm for the cobalt-chromium-molybdenum alloy, stainless steel alloy (SUS), titanium alloy (Ti), smooth surface, and thick cement mantle models, respectively; for the fixation with 10° of flexion (considering flexure), the PPFH50 values were 77 ± 5, 85 ± 9, 90 ± 2, 89 ± 5, and 81 ± 11 cm, respectively. The fracture rates of the polished-surface stems were 78.6 and 35.7% at the proximal and distal sites, respectively (p < 0.05); the fracture rates of the smooth-surface stems were 14.2 and 100%, respectively (p < 0.05). CONCLUSION The impact tests demonstrated that the conditions that were less likely to cause PPFs were use of Ti, a smooth surface, a thick cement mantle, and probably, use of SUS.
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Affiliation(s)
- Takuma Yagura
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Kenichi Oe
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.
| | - Fumito Kobayasi
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Shohei Sogawa
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Tomohisa Nakamura
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Hirokazu Iida
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
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Wakama H, Okamoto Y, Okayoshi T, Ikeda K, Matsuyama J, Otsuki S, Neo M. Unfavorable cortical hypertrophy potentially predisposes to periprosthetic "axe splitter" fracture in a collarless polished curved triple-tapered cemented stem: The time-dependent radiographic change in five SC-stem cases. J Orthop Sci 2024; 29:439-444. [PMID: 36182639 DOI: 10.1016/j.jos.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/20/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The periprosthetic fracture of cemented polished tapered stems is occasionally called a "unique" or "axe splitter" fracture. However, there has been insufficient evidence regarding the association between the radiographic findings prior to incidence and this cumbersome fracture. To determine if there are any radiographic interpretations associated with this fracture pattern, we report the five SC-stem cases with total hip arthroplasty. METHODS We investigate the patient characteristics and serial radiographs of five fracture cases and evaluate the time-dependent specific radiographical changes around the stem between pre-arthroplasty and fracture. RESULTS Fractures developed at 3.5-6.4 years after surgery with low-grade injury or with no particular incentive. Femoral cortical hypertrophy at the distal medial side around the stem was observed in all cases before the development of fractures, at 2-6 years after primary surgery. The duration between cortical hypertrophy appearance to the development of fracture was 0.4-3.1 years. CONCLUSIONS The appearance of this zone-specific cortical hypertrophy might play a key role in the occurrence of periprosthetic fractures. Further studies with larger sample sizes should be conducted to elucidate this eccentric periprosthetic fracture.
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Affiliation(s)
- Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan.
| | - Yoshinori Okamoto
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Tomohiro Okayoshi
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Kuniaki Ikeda
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Junya Matsuyama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki Osaka, Japan
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Kaneuji A, Chen M, Takahashi E, Takano N, Fukui M, Soma D, Tachi Y, Orita Y, Ichiseki T, Kawahara N. Collarless Polished Tapered Stems of Identical Shape Provide Differing Outcomes for Stainless Steel and Cobalt Chrome: A Biomechanical Study. J Funct Biomater 2023; 14:jfb14050262. [PMID: 37233372 DOI: 10.3390/jfb14050262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/24/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023] Open
Abstract
Cemented polished tapered femoral stems (PTS) made of cobalt-chrome alloy (CoCr) are a known risk factor for periprosthetic fracture (PPF). The mechanical differences between CoCr-PTS and stainless-steel (SUS) PTS were investigated. CoCr stems having the same shape and surface roughness as the SUS Exeter® stem were manufactured and dynamic loading tests were performed on three each. Stem subsidence and the compressive force at the bone-cement interface were recorded. Tantalum balls were injected into the cement, and their movement was tracked to indicate cement movement. Stem motions in the cement were greater for the CoCr stems than for the SUS stems. In addition, although we found a significant positive correlation between stem subsidence and compressive force in all stems, CoCr stems generated a compressive force over three times higher than SUS stems at the bone-cement interface with the same stem subsidence (p < 0.01). The final stem subsidence amount and final force were greater in the CoCr group (p < 0.01), and the ratio of tantalum ball vertical distance to stem subsidence was significantly smaller for CoCr than for SUS (p < 0.01). CoCr stems appear to move more easily in cement than SUS stems, which might contribute to the increased occurrence of PPF with the use of CoCr-PTS.
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Affiliation(s)
- Ayumi Kaneuji
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Mingliang Chen
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
- Department of Orthopaedics, Affiliated Renhe Hospital of China Three Gorges University, Yichang 443000, China
| | - Eiji Takahashi
- Department of Orthopaedics, Affiliated Renhe Hospital of China Three Gorges University, Yichang 443000, China
| | - Noriyuki Takano
- Department of Mechanical Engineering, Kanazawa Institution of Technology, Nonoichi 921-8501, Japan
| | - Makoto Fukui
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Daisuke Soma
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Yoshiyuki Tachi
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Yugo Orita
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Toru Ichiseki
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
| | - Norio Kawahara
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun 920-0293, Japan
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Takegami Y, Seki T, Osawa Y, Imagama S. Comparison of periprosthetic femoral fracture torque and strain pattern of three types of femoral components in experimental model. Bone Joint Res 2022; 11:270-277. [PMID: 35514237 PMCID: PMC9130673 DOI: 10.1302/2046-3758.115.bjr-2021-0375.r2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS Periprosthetic hip fractures (PPFs) after total hip arthroplasty are difficult to treat. Therefore, it is important to identify modifiable risk factors such as stem selection to reduce the occurrence of PPFs. This study aimed to clarify differences in fracture torque, surface strain, and fracture type analysis between three different types of cemented stems. METHODS We conducted biomechanical testing of bone analogues using six cemented stems of three different types: collarless polished tapered (CPT) stem, Versys Advocate (Versys) stem, and Charnley-Marcel-Kerboull (CMK) stem. Experienced surgeons implanted each of these types of stems into six bone analogues, and the analogues were compressed and internally rotated until failure. Torque to fracture and fracture type were recorded. We also measured surface strain distribution using triaxial rosettes. RESULTS There was a significant difference in fracture torque between the three stem types (p = 0.036). Particularly, the median fracture torque for the CPT stem was significantly lower than that for the CMK stem (CPT vs CMK: 164.5 Nm vs 200.5 Nm; p = 0.046). The strain values for the CPT stem were higher than those for the other two stems at the most proximal site. The fracture pattern of the CPT and Versys stems was Vancouver type B, whereas that of the CMK stem was type C. CONCLUSION Our study suggested that the cobalt-chromium alloy material, polished surface finish, acute-square proximal form, and the absence of a collar may be associated with lower fracture torque, which may be related to PPF. Cite this article: Bone Joint Res 2022;11(5):270-277.
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Affiliation(s)
- Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taisuke Seki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Osawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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