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Sasaki K, Fujita H, Iwase T, Sakurai T, Oura H, Morishima T, Nishisaka F, Shibanuma N, Katayama N, Ishii M, Otsuka H. Four stem fractures in a 12-year follow-up study of 9,135 patients with Exeter hip stems at seven teaching facilities in Japan. J Orthop Sci 2025; 30:346-351. [PMID: 38871632 DOI: 10.1016/j.jos.2024.05.005] [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: 03/08/2024] [Revised: 05/16/2024] [Accepted: 05/29/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Although excellent long-term results have been reported for the Exeter stem, stem fracture is recognized as a rare complication. However, there have been no reports on the incidence and risk factors for stem fractures based on detailed population information. This study aimed to clarify the incidence of Exeter hip stem fracture based on detailed population information from seven Exeter stem teaching centers in Japan and to examine the risk factors for stem fracture. METHODS A total of 8,499 primary total hip arthroplasties (THA) and 636 revision hip arthroplasties (revisions) performed at seven Exeter teaching hospitals between 1999 and 2021 were included and retrospectively investigated based on medical records. RESULTS Stem fractures were identified in two primary THA (fracture rate: 0.02%) and two revision THA (fracture rate: 0.21%) cases. The stem length was ≤125 mm in three out of these four cases. Revision and 30 stem were the risk factors for stem fractures. Weight and body mass index (BMI) were not significantly associated with the occurrence of stem fractures. CONCLUSIONS In Western countries, the incidence of Exeter stem fractures is reportedly 0.017-0.15% for primary THA and 0.99-1.21% for revision THA. In this study, the incidence of primary THA was 0.02%, which is similar to the lowest reported rate, whereas the incidence of revision THA was 0.21%, which is lower than that reported in previous studies. Revision surgery had the same risk factors as those reported in the West-namely, stem length ≤125 mm (except for the 30 stem) and BMI, which were not risk factors in Japanese patients.
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Affiliation(s)
- Kan Sasaki
- Department of Orthopedic Surgery, Yamagata Saisei Hospital, Yamagata, 990-8545, Japan.
| | - Hiroshi Fujita
- Center for Hip Arthroplasty, Senshunkai Hospital, Nagaokakyo, Kyoto, 617-0826, Japan
| | - Toshiki Iwase
- Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Shizuoka, 432-8580, Japan
| | - Tatsuro Sakurai
- Department of Orthopedic Surgery, Nagareyama Central Hospital, Nagareyama, Chiba, 270-0114, Japan
| | - Hisanori Oura
- Department of Orthopedic Surgery, Hokkaido Orthopedic Memorial Hospital, Sapporo, Hokkaido, 062-0937, Japan
| | - Takkan Morishima
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, 480-1195, Japan
| | - Fumiaki Nishisaka
- Department of Orthopedic Surgery, Osaka Rehabilitation Hospital, Hannan, Osaka, 599-0212, Japan
| | - Nao Shibanuma
- Department of Orthopedic Surgery, Kobe Kaisei Hospital, Nada-ku, Kobe, 657-0068, Japan
| | - Naoyuki Katayama
- Department of Orthopedic Surgery, Hokkaido Orthopedic Memorial Hospital, Sapporo, Hokkaido, 062-0937, Japan
| | - Masaji Ishii
- Department of Orthopedic Surgery, Yamagata Saisei Hospital, Yamagata, 990-8545, Japan
| | - Hiromi Otsuka
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, 480-1195, Japan
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Chung BC, Kumaran P, Heckmann ND, Oakes DA. Fracture of the Proximal Body of a Modern Cementless Modular Fluted Tapered Stem. Arthroplast Today 2024; 29:101472. [PMID: 39185401 PMCID: PMC11344007 DOI: 10.1016/j.artd.2024.101472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 08/27/2024] Open
Abstract
Previous reports have described failures of modular fluted tapered femoral stems secondary to fatigue failure at the modular junction. However, the present study is the first reported case of modular fluted tapered femoral component failure involving atraumatic fracture of the proximal body following revision total hip arthroplasty. The failure occurred in a 52-year-old female with a history of postmenopausal osteoporosis on bisphosphonates who sustained an atraumatic fracture of the proximal body of a modular revision femoral stem. In the present case, revision THA utilizing a wider proximal body segment with proximal augmentation using strut allografts for biological and mechanical support provided the patient with a stable construct at 30-month follow-up.
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Affiliation(s)
- Brian C. Chung
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Pranit Kumaran
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Nathanael D. Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Daniel A. Oakes
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
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Ruhland ED, Antonoff DG, Mesko DR. Fracture of an Exeter Femoral Stem With Extensive Ipsilateral Periacetabular Osteolysis. Arthroplast Today 2024; 29:101436. [PMID: 39347378 PMCID: PMC11437756 DOI: 10.1016/j.artd.2024.101436] [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: 03/02/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 10/01/2024] Open
Abstract
The Stryker Exeter stem (Stryker, Kalamazoo, MI) has been in service for over 50 years and remains the most widely used cemented stem. Stem fracture is a rare complication, with recently reported rates of 1 in 10,000. We present a case of Exeter stem fracture 25 years following initial implantation as well as a large periacetabular defect secondary to osteolysis. A revision total hip arthroplasty was performed, including periacetabular bone grafting for extensive osteolysis along with retention of a stable acetabular component. This case highlights the rare complication of Exeter stem fracture as well as the technique of bone grafting a large periacetabular defect with a retained acetabular component. This is of particular interest given the rarity of this event and the resurgence in North America of cemented femoral components in total hip arthroplasty.
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Affiliation(s)
- Ethan D. Ruhland
- Department of Orthopedic Surgery, McLaren Greater Lansing Hospital, Lansing, MI, USA
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
- Michigan Orthopedic Center, Lansing, MI, USA
| | - Daniel G. Antonoff
- Department of Orthopedic Surgery, McLaren Greater Lansing Hospital, Lansing, MI, USA
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Daniel R. Mesko
- Department of Orthopedic Surgery, McLaren Greater Lansing Hospital, Lansing, MI, USA
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
- Michigan Orthopedic Center, Lansing, MI, USA
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Lucero CM, Luco JB, Garcia-Mansilla A, Slullitel PA, Zanotti G, Comba F, Buttaro MA. Successful hip revision surgery following refracture of a modern femoral stem using a cortical window osteotomy technique: A case report and review of literature. World J Methodol 2023; 13:502-509. [PMID: 38229936 PMCID: PMC10789112 DOI: 10.5662/wjm.v13.i5.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/26/2023] [Accepted: 09/11/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND The ExeterTM Universal cemented femoral component is widely used for total hip replacement surgery. Although there have been few reports of femoral component fracture, removal of a broken femoral stem can be a challenging procedure. CASE SUMMARY A 54-year-old man with a Dorr A femur sustained a refracture of a primary ExeterTM stem, two years after receiving a revision using a cement-within-cement technique (CWC) through an extended trochanteric osteotomy (ETO). The technical problems related to the CWC technique and the ETO played a major role in the stem fatigue refracture. We performed revision surgery and removed the distal cement using a cortical femoral window technique, followed by re-implantation with an uncemented, modular, distally-fixed uncemented stem. The patient experienced an uneventful postoperative recovery. CONCLUSION Re-fracture of a modern femoral ExeterTM stem is a rare event, but technical complications related to revision surgery can lead to this outcome. The cortical window osteotomy technique can facilitate the removal of a broken stem and cement, allowing for prosthetic re-implantation under direct vision and avoiding ETO-related complications.
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Affiliation(s)
- Carlos M Lucero
- Centro de Cadera "Sir John Charnley", Instituto de Ortopedia y Traumatologia Prof. Dr. Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Capital federal C1198AAW, Buenos Aires, Argentina
| | - Juan B Luco
- Instituto de Ortopedia y Traumatologia Prof. Dr. Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires C1198AAW, Buenos Aires, Argentina
| | - Agustin Garcia-Mansilla
- Centro de Cadera "Sir John Charnley", Instituto de Ortopedia y Traumatología, “Prof. Dr. Carlos E. Ottolenghi”, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires C1198AAW, Buenos Aires, Argentina
| | - Pablo A Slullitel
- Centro de Cadera "Sir John Charnley", Instituto de Ortopedia y Traumatología, “Prof. Dr. Carlos E. Ottolenghi”, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires C1198AAW, Buenos Aires, Argentina
| | - Gerardo Zanotti
- Centro de Cadera "Sir John Charnley", Instituto de Ortopedia y Traumatologia Prof. Dr. Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Capital federal C1198AAW, Buenos Aires, Argentina
| | - Fernando Comba
- Centro de Cadera "Sir John Charnley", Instituto de Ortopedia y Traumatologia Prof. Dr. Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Capital federal C1198AAW, Buenos Aires, Argentina
| | - Martin A Buttaro
- Centro de Cadera "Sir John Charnley", Instituto de Ortopedia y Traumatologia Prof. Dr. Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Capital federal C1198AAW, Buenos Aires, Argentina
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Malhotra R, Gautam D, Gupta S. A New Type of Periprosthetic Fracture: Is It the Time to Update the Unified Classification System? Indian J Orthop 2021; 55:1277-1285. [PMID: 34629498 PMCID: PMC8487673 DOI: 10.1007/s43465-021-00538-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/27/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Increased number of primary and revision arthroplasties performed globally has led to a surge in the numbers of periprosthetic fractures. The Unified Classification System (UCS) advocated a rational approach towards the classification of periprosthetic fractures. We present here an update to the UCS with addition of new fracture pattern encountered in orthopedic practice. METHODS A retrospective study was conducted to review the service arthroplasty register for the cases with unique fracture pattern where the periprosthetic fracture around total hip arthroplasty was also associated with fracture of the prosthetic component. The details were retrieved from the medical record and the patients were called for a review. The radiological assessment was done with X-rays and clinical assessment with Harris Hip Scores at the latest follow-up. RESULTS Between 2012 and 2019, 11 patients (7 males and 4 females) were operated for peri-prosthetic fracture with a unique pattern where the fracture of femur was associated with fracture of the femoral stem as well. The mean age of the patient at the time of fracture was 56.8 years (range 42-71 years). All patients were managed with revision hip surgery. One patient died due to malignancy after 7 years of revision surgery. All the surviving patients are doing well with a mean Harris Hip Score of 86.8 at the latest follow-up of 2-9 years (mean 5.0 years). CONCLUSION With emergence of this new fracture pattern, it is recognition as a separate entity would help in better understanding and augmentation of the existing classification system of periprosthetic fractures.
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Affiliation(s)
- Rajesh Malhotra
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, 110029 India
| | - Deepak Gautam
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, 110029 India
| | - Saurabh Gupta
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, 110029 India
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Thompson JW, Corbett J, Bye D, Jones A, Tissingh EK, Nolan J. Analysis of the Exeter V40 femoral stem prosthesis fracture : systematic review and single centre case series. Bone Jt Open 2021; 2:443-456. [PMID: 34176335 PMCID: PMC8244800 DOI: 10.1302/2633-1462.26.bjo-2021-0025.r1] [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] [Indexed: 11/23/2022] Open
Abstract
Aims The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems. Methods A systematic literature search was performed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. In parallel, we performed a retrospective single centre study of Exeter V40 femoral stem prosthetic fractures between April 2003 and June 2020. Results There are 25 reported cases of such prosthetic fractures confined to small case series and case reports within the literature. We report an additional 19 cases to the literature (mean age 66.3 years (SD 11.7); 12 (63%) females; BMI 32.9 kg/m2 (SD 5.9)). The mean time from index procedure to fracture was 7.8 years (SD 3.6; 2.5 to 16.3). Exeter V40 stem fracture incidence was 0.15% and 1.21% for primary and revision arthroplasty, respectively. Incidence was significantly higher in revision arthroplasty (p < 0.001) and 125 mm length stems compared to ≥ 150 mm length stems (1.25% vs 0.13%, respectively; p < 0.001). When comparing different stem length cohorts, 125 mm short-stems were associated with stem-body fractures (92% vs 29%; p = 0.0095), earlier time to fracture (6.2 years vs 11.0 years; p = 0.0018), younger patient age at time of fracture (62.7 years vs 72.6 years; p = 0.037), and female sex (75% vs 43%; p = 0.326). Conclusion This complication remains rare, although we report a significantly higher incidence at up to 17 years follow-up than in the literature. Short 125 mm length Exeter V40 stems undoubtedly have a role in restoring anatomy and biomechanics in smaller femoral geometries, although the surgeon has to appreciate the higher risk of stem fracture and the associated predisposing factors which may necessitate particular attention to surgical technique and planning. Cite this article: Bone Jt Open 2021;2(6):443–456.
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Affiliation(s)
- Joshua W Thompson
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
| | - James Corbett
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
| | - Daniel Bye
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
| | - Adrian Jones
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
| | - Elizabeth K Tissingh
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
| | - John Nolan
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
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van Doesburg PG, van Langelaan EJ, Apachitei I, Bénard MR, Verdegaal SHM. Femoral prosthesis neck fracture following total hip arthroplasty - a systematic review. ARTHROPLASTY 2020; 2:28. [PMID: 35236443 PMCID: PMC8796592 DOI: 10.1186/s42836-020-00047-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/17/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Head-neck modularity was introduced into total hip arthroplasty to provide more intraoperative surgical options. However, modularity led to new problems, such as trunnionosis and fractures of the femoral prosthesis neck. The purpose of this study was to identify risk factors for hip neck fractures and to provide recommendations to prevent damage and fractures of the neck. METHODS A systematic review of the literature was performed according to the PRISMA guidelines. RESULTS Thirty-three case studies were included. Methodologically, most included studies were of moderate or good quality. The 80 neck fractures included in the review took place, on average, 7 years after stem placement. Male gender, high body weight, obesity, previous revision surgery, mixing components from different manufacturers, use of long skirted heads, cobalt-chromium (large size) heads were identified as potential risk factors. CONCLUSION Hip neck fractures occur on average 7 years after stem placement. The etiology of hip neck fractures is multifactorial. This review revealed several preventable implant- and surgeon-related risk factors.
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Affiliation(s)
- P G van Doesburg
- Department of Orthopaedic Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands.
| | - E J van Langelaan
- Biomechanical Engineering Department Biomaterials & Tissue Biomechanics Section, Delft University of Technology, Delft, The Netherlands
| | - I Apachitei
- Biomechanical Engineering Department Biomaterials & Tissue Biomechanics Section, Delft University of Technology, Delft, The Netherlands
| | - M R Bénard
- Department of Orthopaedic Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
| | - S H M Verdegaal
- Department of Orthopaedic Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
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Femoral stem fractures after primary and revision hip replacements: A single-center experience. Jt Dis Relat Surg 2020; 31:557-563. [PMID: 32962589 PMCID: PMC7607938 DOI: 10.5606/ehc.2020.76162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objectives
This study aims to present our experience in the management of fractured femoral stems after primary and revision hip replacements by evaluating the clinical and radiographic characteristics and determining the effectiveness of the extraction methods. Patients and methods
A total of 15 patients (5 males, 10 females; mean age 65.9 years; range, 49 to 87 years) who underwent revision hip replacement due to a fractured femoral stem between January 2005 and December 2019 were included in this retrospective study. The mechanisms and risk factors for failure as well as methods applied to extract fractured stem were analyzed through clinical and radiographic data. Results
Nine patients had fractured cemented femoral stems, while six patients had fractured fully porous coated cementless revision stems. Lack of proximal buttress in distally fixed femoral stems was detected in 11 patients and identified as the predominant mechanism resulting in fracture. The proximal extraction method with conventional revision instrumentation, the cortical window technique, and extended trochanteric osteotomy (ETO) were used in three, seven, and five cases, respectively. Conclusion Our results demonstrated that the lack of proximal buttress is the most common reason for femoral stem fracture. Moreover, the proximal extraction method was mostly ineffective in fully porous femoral stems. A step-by-step approach should be considered for the extraction of a broken stem. The cortical window method can be considered as the second step if proximal extraction methods fail, and ETO should be considered at the last step if all techniques fail.
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Early Surgical Complications of Total Hip Arthroplasty in Patients With Morbid Obesity: Propensity-Matched Cohort Study of 3683 Patients. J Arthroplasty 2020; 35:2646-2651. [PMID: 32418743 DOI: 10.1016/j.arth.2020.04.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study is to determine whether the high risk of surgical complications within 1 year of total hip arthroplasty (THA) is due to associated comorbidities or morbid obesity alone as measured by body mass index (BMI ≥ 40 kg/m2). METHODS Population-based retrospective cohort study was conducted of all adults in Ontario undergoing primary THA for osteoarthritis (2012-2018). All patients were followed for 1 year. Outcomes were compared among matched groups (hypertension, diabetes, chronic obstructive pulmonary disease, frailty, congestive heart failure, coronary artery disease, asthma, and Charlson score). Primary outcome measure was major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, and revision surgery). RESULTS A total of 3683 patients with morbid obesity were matched and had a significantly greater risk of major complications within 1-year (132 [3.6%] vs 54 [1.5%]; hazard ratio [HR] 2.54, 95% confidence interval [CI]; 1.98-3.25). This included greater risk for deep infection requiring surgery (100 [2.8%] vs 26 [0.7%]; HR 3.85, 95% CI; 2.70-45.48) and revision arthroplasty (86 [2.4%] vs 34 [0.9%]; HR 2.61, 95% CI; 1.92-3.55). Operative time was also longer with a median 116 (99-138) vs 102 (87-121) minutes. There were no significant differences in hospital stay, cost of acute care episode, or medical complications. CONCLUSION Patients' large body habitus seems to contribute to the increased risk of surgical complications within 1-year of THA. Future research is needed to identify ways of mitigating surgical complications such as centralizing care for this complex group of patients in specialist centers.
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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: 1.8] [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.
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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
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Matar HE, Selvaratnam V, Board TN, Purbach B, Porter ML, Kay PR, Shah N. Fractured Femoral Stems in Primary and Revision Hip Arthroplasties Revisited: Wrightington Experience. J Arthroplasty 2020; 35:1344-1350. [PMID: 32014380 DOI: 10.1016/j.arth.2020.01.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/30/2019] [Accepted: 01/09/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this study is to present our experience in managing fractured femoral stems over the last 10 years for both primary and revision stems at our tertiary unit focusing on modes of failure and operative techniques. METHODS This is a retrospective consecutive study of all patients with fractured femoral stems that were operatively managed in our unit between 2008 and 2018. Detailed radiographic evaluation (Paprosky classification) was undertaken and data collected on operative techniques used to extract distal fractured stem fragments. RESULTS Thirty-five patients (35 hips) were included (25 men/10 women) with average age at time of presentation of 68 years (range, 29-93). Average body mass index was 30 (standard deviation, 3.8; range, 22.5-39). There were variety of stems both contemporary and historical, primary and revision cases (15 hips polished tapered cemented stems, 10 hips composite beam and miscellaneous stems, and 10 revision hip stems). The predominant mechanism of failure was fatigue due to cantilever bending in distally fixed stems. Surgical techniques used to extract distal fragment were drilling technique in 2 hips, cortical window in 13 hips, extended trochanteric osteotomy (ETO) in 5 hips, and proximal extraction in 15 hips. CONCLUSION When faced with a contemporary fractured stem, drilling techniques into the distal fragment are unlikely to succeed. If a trochanteric osteotomy had been used at time of index surgery, this could be used again to aid proximal extraction with conventional revision instrumentations. The cortical window technique is useful but surgically demanding technique that is most successful in extracting polished tapered fractured stems particularly when an ETO is not planned for femoral reconstruction. Use of trephines can be useful for removal of longer, uncemented stems. Finally, an ETO might be necessary when other techniques have failed.
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Affiliation(s)
- Hosam E Matar
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
| | | | - Tim N Board
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
| | - Bodo Purbach
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
| | | | - Peter R Kay
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
| | - Nikhil Shah
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
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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: 0.4] [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.
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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
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Alp N, Guney N. Bilateral Universal Exeter™ Femoral Stem Fracture. J Orthop Case Rep 2019; 9:48-50. [PMID: 32405487 PMCID: PMC7210910 DOI: 10.13107/jocr.2019.v09.i04.1474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Total hip arthroplasty(THA) in dysplastic hips involves technical difficulties due to impaired anatomy. Specially designed implants are needed for dysplastic hips. Usage of these implants with appropriate material and design features reduces the pain in this group of patients and increases the standard of life. Improper implant selection causes various complications. The presented case is about a 62-year-old female patient who was operated bilaterally for coxarthrosis secondary to developmental hip dysplasia. She had minimal complaints during her last outpatient follow-up. Radiographs revealed a fracture of the simultaneous bilateral femoral stem. Case Report: Seventeen years ago, a 45-year-old lady was admitted to our hospital due to coxarthrosis secondary to developmental hip dysplasia. In six months interval, she underwent bilateral THA with Exeter™ Universal Hip system.She had re-operated on her 3rd year because of right femoral stem fracture.Since then, she has beenexamined at the outpatient clinic regularly on1-year-based intervals. There was no trauma or obvious activity experienced. Radiographs of the pelvis and bilateral femur were obtained, andit was demonstrated that both femoral stems were broken. Both fractured stems were removed by extended femoral osteotomy via a lateral approach.Intraoperative examination revealedthat the right acetabular component was well-fixed, but there was a loosening of the left acetabularcomponent. The acetabular revision was performed to the left side. Echelon cementless revision hip system (Smith and Nephew) was used for the right and left sides. The patient was stood–up on the first post-operative day and weight-bearing was permitted as much as tolerated. At the end of 6 weeks, full weight bearing was permitted. She was returned to her routine daily life activities after 4 months. Conclusion: After the acquisition of Howmedica by Stryker in 1998, the taper in the Exeter stem was modified, and a new Exeter V40 stem concept was introduced in 2001, but still in literature, we could comeacross stem fracture cases. We may not eliminate all prosthetic fractures, but we may reduce them as low as possible by doing appropriate cementing, placing the stem in proper alignment and for us, the most important one is pre-operative templating. Spending some time in front of X-rays and choosing the appropriate size of a stem is the most helpful step while eliminating the prosthetic fractures.
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Affiliation(s)
- NazmiBulent Alp
- Department of Orthopedics and Traumatology, Faculty of Medical, Bursa Uludag Unıversity, Bursa, Turkey
| | - Nejat Guney
- Department of Orthopaedics and Traumatology, Nısantası Orthopedics Center, Private Practice, Sisli-İstanbul, Turkey
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14
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Al Habsi S, Luthra J, Al Badei H. Taper Fracture of Uncemented Femoral Stem after Total Hip Arthroplasty. CASE REPORTS IN ORTHOPEDIC RESEARCH 2018. [DOI: 10.1159/000495359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Fracture through the tapered femoral neck of total hip arthroplasty is extremely rare. We report the taper neck fracture of a cementless stem in an extensively porous-coated femoral prosthesis used for total hip arthroplasty due to chronic hip infection 8 years previously in a 42-year-old man, weighing 110 kg with a body mass index of 39. We consider that cyclical loading stresses, fretting corrosion, and high body mass index are possible potential risk factors of such fracture.
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15
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An Analysis of Reported Cases of Fracture of the Universal Exeter Femoral Stem Prosthesis. J Arthroplasty 2017; 32:1318-1322. [PMID: 27843041 DOI: 10.1016/j.arth.2016.09.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 08/31/2016] [Accepted: 09/26/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Between 1991 and 2008, approximately 80 cases of fracture (neck or stem) have been reported. This study aimed at determining factors predisposing to implant fracture. METHODS Clinical, surgical, radiological, and retrieval data were collated. Risk factors associated with fracture were categorized to patient related (weight and activity levels), surgical related (poor medial support, component size, and placement), and anatomic/implant related (head size/offset). RESULTS Data was available on 60 patients (32 stem and 28 neck fractures). Mean patient age at fracture was similar for both neck and stem fractures (69 years, 67 years, respectively). Also, 77% neck and 52% stem fractures occurred in men. Mean weight was 107 kg in neck and 96.5 kg in stem fractures with 68% neck and 38% stem fractures either obese or morbidly obese. Mean time to fracture was 78 months (range, 36-144 months) for neck and 76 months (range, 2-155 months) for stem fractures. 44#2 and 44#3 were the most common sizes associated with neck fractures. Stem fractures occurred more commonly (84%) in the smaller sizes (35.5 to 44#1). Elongated femoral heads were used in 69% neck and 14% stem fractures. CONCLUSION Neck fractures were most commonly associated with patient-related (increased weight and activity) and implant-related (use of an elongated femoral head) factors. Stem fractures were most commonly associated with correctable surgical-related causes, predominantly secondary to stem undersizing or inadequate medial support (84%).
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16
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The effect of cement on hip stem fixation: a biomechanical study. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:349-357. [PMID: 28321636 DOI: 10.1007/s13246-017-0539-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
Abstract
This study presents the numerical analysis of stem fixation in hip surgery using with/without cement methods since the use of cement is still controversial based on the clinical studies in the literature. Many different factors such as stress shielding, aseptic loosening, material properties of the stem, surgeon experiences etc. play an important role in the failure of the stem fixations. The stem fixation methods, cemented and uncemented, were evaluated in terms of mechanical failure aspects using computerized finite element method. For the modeling processes, three dimensional (3D) femur model was generated from computerized tomography (CT) images taken from a patient using the MIMICS Software. The design of the stem was also generated as 3D CAD model using the design parameters taken from the manufacturer catalogue. These 3D CAD models were generated and combined with/without cement considering the surgical procedure using SolidWorks program and then imported into ANSYS Workbench Software. Two different material properties, CoCrMo and Ti6Al4V, for the stem model and Poly Methyl Methacrylate (PMMA) for the cement were assigned. The material properties of the femur were described according to a density calculated from the CT images. Body weight and muscle forces were applied on the femur and the distal femur was fixed for the boundary conditions. The calculations of the stress distributions of the models including cement and relative movements of the contacts examined to evaluate the effects of the cement and different stem material usage on the failure of stem fixation. According to the results, the use of cement for the stem fixation reduces the stress shielding but increases the aseptic loosening depending on the cement crack formations. Additionally, using the stiffer material for the stem reduces the cement stress but increases the stress shielding. Based on the results obtained in the study, even when taking the disadvantages into account, the cement usage is more suitable for the hip fixations.
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17
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Craik JD, Bircher MD, Rickman M. Hip and knee arthroplasty implants contraindicated in obesity. Ann R Coll Surg Engl 2016; 98:295-9. [PMID: 27023636 PMCID: PMC5227026 DOI: 10.1308/rcsann.2016.0103] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION High patient weight is a risk factor for mechanical implant failure and some manufacturers list obesity as a contraindication for implant use. We reviewed data from the 2012-2013 UK National Joint Registry to determine whether surgical practice reflects these manufacturer recommendations. METHODS The product literature for the most commonly used hip and knee implants was reviewed for recommendations against use in obese patients (body mass index [BMI] ≥ 30kg/m(2)). The total number of obese patients undergoing hip and knee arthroplasty was calculated, as was the proportion receiving implants against manufacturer recommendations. RESULTS Out of 200,054 patient records, 147,691 (74%) had a recorded BMI. The mean BMI for patients undergoing primary total hip arthroplasty was 29kg/m(2), compared with 31kg/m(2) for total knee arthroplasty. Of the 25 components reviewed, 5 listed obesity as a contraindication or recommended against implant use in obese patients. A total of 10,745 patients (16% of all obese patients) received implants against manufacturer recommendations. CONCLUSIONS A high proportion of patients are receiving implants against manufacturer recommendations. However, there are limitations to using BMI for stratifying risk of implant fatigue failure and manufacturers should therefore provide more detailed guidelines on size specific implant load limits to facilitate surgical decisions.
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Affiliation(s)
- J D Craik
- St George's University Hospitals NHS Foundation Trust , UK
| | - M D Bircher
- St George's University Hospitals NHS Foundation Trust , UK
| | - M Rickman
- St George's University Hospitals NHS Foundation Trust , UK
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18
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Merini A, Viste A, Desmarchelier R, Fessy MH. Cementless Corail™ femoral stems with laser neck etching: Long-term survival, rupture rate and risk factors in 295 stems. Orthop Traumatol Surg Res 2016; 102:71-6. [PMID: 26726098 DOI: 10.1016/j.otsr.2015.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/14/2015] [Accepted: 10/19/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Implant neck fracture involving a non-modular femoral stem is rare in primary total hip arthroplasty (THA). Occasional cases have been reported following laser etching of the Corail(tm) stem, but risk factors have not been precisely determined. We therefore performed a retrospective study on a series of Corail(tm) stems with laser neck etching, in order to: (1) determine the exact implant neck fracture rate at 10 years, and (2) identify associated risk factors. HYPOTHESIS Laser etching increases the rate of implant neck fracture. MATERIALS AND METHODS Between October 2002 and December 2003, 295 THAs were consecutively performed using the Corail(tm) stem with laser neck etching, in 286 patients: 151 male (53%), 135 female (47%); mean age, 63 years (range, 18-89 years); mean weight, 73kg (range, 45-120kg). Stems were standard in 240 cases (81%) and lateralized in 55 (19%). The main assessment criterion was stem replacement for implant neck fracture. RESULTS At a mean 10 years' follow-up (range, 1-11 years), 11 patients were lost to follow-up (4%) and 35 had died (12%) (with stem in situ). Overall 10-year stem survival was 91% (95% CI: [87-94%]). Sixteen patients (5.4%) underwent revision surgery for implant neck fracture, 6 (2%) bone and joint infection and in 4 cases (1.3%) the stem was replaced preventively for fracture risk suspected during a revision procedure on the cup. All fractures were of the fatigue type, implicating implant neck laser etching. Mean time to fracture was 4.5 years (range, 1.4-9.8 years). Risk factors comprised: weight>80kg (P=0.002) (OR=5.7; 95% CI: 1.9-17), age<60 years (P=0.02) (OR=3.4; 95% CI: 1.2-9.6), male gender (P=0.01) (OR=14.8; 95% CI: 1.9-113) and lateralized stem (P<0.001) (OR=6.5, 95% CI: 2.3-18). CONCLUSION The present 5.4% fracture rate was higher than in registry data (<1%). Fracture mechanisms involved excessive stress in an area under tension, leading to fatigue fracture. Male gender, high weight and young age were risk factors, as in the literature for fatigue fracture. Location and depth of laser etching induced fatigue fracture. The study demonstrated that laser etching creates an area of weakness in the implant neck and should therefore be eschewed in this part of the femoral stem. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- A Merini
- Hospices civils de Lyon, centre hospitalier Lyon-Sud, service de chirurgie orthopedique et traumatologique, 165, chemin Grand-Revoyet, 69495 Pierre-Bénite cedex, France
| | - A Viste
- Hospices civils de Lyon, centre hospitalier Lyon-Sud, service de chirurgie orthopedique et traumatologique, 165, chemin Grand-Revoyet, 69495 Pierre-Bénite cedex, France; Université de Lyon, 69622 Lyon, France; Université Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre, 69100 Villeurbanne, France; IFSTTAR, UMRT 9406, laboratoire de biomécanique et mécanique des chocs, 25, avenue Mitterrand, 69500 Bron, France.
| | - R Desmarchelier
- Hospices civils de Lyon, centre hospitalier Lyon-Sud, service de chirurgie orthopedique et traumatologique, 165, chemin Grand-Revoyet, 69495 Pierre-Bénite cedex, France
| | - M-H Fessy
- Hospices civils de Lyon, centre hospitalier Lyon-Sud, service de chirurgie orthopedique et traumatologique, 165, chemin Grand-Revoyet, 69495 Pierre-Bénite cedex, France; Université de Lyon, 69622 Lyon, France; Université Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre, 69100 Villeurbanne, France; IFSTTAR, UMRT 9406, laboratoire de biomécanique et mécanique des chocs, 25, avenue Mitterrand, 69500 Bron, France
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19
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Chun YS, Juh HS, Cho YJ, Rhyu KH. Fracture of Fully-coated Femoral Stem after Primary Total Hip Arthroplasty for Nonunion of Intertrochanteric Fracture: A Case Report. Hip Pelvis 2015; 27:179-82. [PMID: 27536622 PMCID: PMC4972723 DOI: 10.5371/hp.2015.27.3.179] [Citation(s) in RCA: 2] [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: 05/21/2015] [Revised: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 12/03/2022] Open
Abstract
Femoral stem fracture is an uncommon reason for the failure of total hip arthroplasty, with only 16 cases of fully coated stem fractures reported to date. Here we report a case in which a fully coated primary femoral stem fracture occurred after conversion to total hip arthroplasty for the non-union of an intertrochanteric fracture of the femur. Metallurgic evaluation of the etiology and mechanism revealed that the fracture was initiated by fatigue-related failure and completed by ductile failure on the posterior side of the fracture. Considering the recent trend of treating an intertrochanteric fracture with hip arthroplasty, possible stem failure should be considered, since most patients will have at least one of the known risk factors for stem fracture.
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Affiliation(s)
- Young Soo Chun
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Hyung Suk Juh
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Yoon Je Cho
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Korea
| | - Kee Hyung Rhyu
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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20
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Chanda S, Dickinson A, Gupta S, Browne M. Full-field in vitro measurements and in silico predictions of strain shielding in the implanted femur after total hip arthroplasty. Proc Inst Mech Eng H 2015; 229:549-59. [DOI: 10.1177/0954411915591617] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/19/2015] [Indexed: 11/16/2022]
Abstract
Alterations in bone strain as a result of implantation may contribute towards periprosthetic bone density changes after total hip arthroplasty. Computational models provide full-field strain predictions in implant–bone constructs; however, these predictions should be verified using experimental models wherever it is possible. In this work, finite element predictions of surface strains in intact and implanted composite femurs were verified using digital image correlation. Relationships were sought between post-implantation strain states across seven defined Gruen zones and clinically observed longer-term bone density changes. Computational predictions of strain distributions in intact and implanted femurs were compared to digital image correlation measurements in two regions of interest. Regression analyses indicated a strong linear correlation between measurements and predictions (R = 0.927 intact, 0.926 implanted) with low standard error (standard error = 38 µε intact, 26 µε implanted). Pre- to post-operative changes in measured and predicted surface strains were found to relate qualitatively to clinically observed volumetric bone density changes across seven Gruen zones: marked proximal bone density loss corresponded with a 50%−64% drop in surface strain, and slight distal density changes corresponded with 4%−14% strain increase. These results support the use of digital image correlation as a pre-clinical tool for predicting post-implantation strain shielding, indicative of long-term bone adaptations.
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Affiliation(s)
- Souptick Chanda
- Department of Mechanical Engineering, Indian Institute of Technology Kharagpur, Kharagpur, India
| | - Alexander Dickinson
- Bioengineering Science Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK
| | - Sanjay Gupta
- Department of Mechanical Engineering, Indian Institute of Technology Kharagpur, Kharagpur, India
| | - Martin Browne
- Bioengineering Science Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK
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21
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Sadoghi P, Pawelka W, Liebensteiner MC, Williams A, Leithner A, Labek G. The incidence of implant fractures after total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2014; 38:39-46. [PMID: 24077887 PMCID: PMC3890121 DOI: 10.1007/s00264-013-2110-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Implant fractures after total hip arthroplasty (THA) are considered as rare in clinical practice. Nevertheless they are relevant complications for patients, physicians, and the public health system leading to high socioeconomic burdens. The aim of this study was to assess the incidence of fractures after THAs in a comparative analysis of clinical studies and worldwide arthroplasty register datasets. METHODS We calculated the pooled incidence of revision operations after fractures of THAs in a comparison of clinical studies published in Medline-listed journals and annual reports of worldwide arthroplasty registers in a structured literature analysis based on a standardised methodology. RESULTS Included clinical studies (sample-based datasets) were mono-centre trials comprising a cumulative number of approximately 70,000 primary implantations whereas worldwide national arthroplasty register datasets referred to 733,000 primary implantations, i.e. approximately ten times as many as sample-based datasets. In general, sample-based datasets presented higher revision rates than register datasets with a maximum deviation of a 14.5 ratio for ceramic heads, respectively. The incidence of implant fractures in total hip arthroplasty in pooled worldwide arthroplasty register datasets is 304 fractures per 100,000 implants. In other words, one out of 323 patients has to undergo revision surgery due to an implant fracture after THA in their lifetime. CONCLUSIONS Implant fractures in total hip arthroplasty occur in a relevant number of patients. The authors believe that comprehensive arthroplasty register datasets allow more general evaluations and conclusions on that topic in contrast to clinical studies.
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Affiliation(s)
- Patrick Sadoghi
- />Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Wolfram Pawelka
- />Department of Orthopaedic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Michael C. Liebensteiner
- />Department of Orthopaedic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Alexandra Williams
- />Department of Orthopaedic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Andreas Leithner
- />Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Gerold Labek
- />Department of Orthopaedic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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22
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Tiberi JV, Spitzer A, Paiement G. Fracture of a Cemented, Highly Polished, Collarless, Triple-Tapered, High-Nitrogen Stainless Steel Femoral Stem: A Case Report. JBJS Case Connect 2013; 3:e103. [PMID: 29252258 DOI: 10.2106/jbjs.cc.l.00240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John V Tiberi
- South Bay Orthopaedic Specialists, 23560 Crenshaw Boulevard, Suite 120, Torrance, CA 90505.
| | - Andrew Spitzer
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd., OC - 603, Los Angeles, CA 90048
| | - Guy Paiement
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd., OC - 603, Los Angeles, CA 90048
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23
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Purbach B, Kay PR, Siney PD, Fleming PA, Wroblewski BM. The C-stem in clinical practice: fifteen-year follow-up of a triple tapered polished cemented stem. J Arthroplasty 2013; 28:1367-71. [PMID: 23528555 DOI: 10.1016/j.arth.2012.10.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 10/11/2012] [Accepted: 10/29/2012] [Indexed: 02/01/2023] Open
Abstract
The triple tapered polished cemented stem, C-Stem, introduced in 1993 was based on the original Charnley concept of the "flat back" polished stem. We present our continuing experience with the C-Stem in 621 consecutive primary arthroplasties implanted into 575 patients between 1993 and 1997. Four hundred and eighteen arthroplasties had a clinical and radiological follow-up past 10 years with a mean follow-up of 13 years (10-15). There were no revisions for stem loosening but 2 stems were revised for fracture - both with a defective cement mantle proximally. The stem design and the surgical technique support the original Charnley concept of limited stem subsidence within the cement mantle and the encouraging results continue to stand as a credit to Sir John Charnley's original philosophy.
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Affiliation(s)
- Bodo Purbach
- John Charnley Research Institute, Wrightington Hospital, WN6 9EP Wigan, UK
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25
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Norman T, Shultz T, Noble G, Gruen T, Blaha J. Bone creep and short and long term subsidence after cemented stem total hip arthroplasty (THA). J Biomech 2013; 46:949-55. [DOI: 10.1016/j.jbiomech.2012.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 11/07/2012] [Accepted: 12/12/2012] [Indexed: 11/24/2022]
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26
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Griffiths EJ, Stevenson D, Porteous MJ. Cost savings of using a cemented total hip replacement: an analysis of the National Joint Registry data. ACTA ACUST UNITED AC 2012; 94:1032-5. [PMID: 22844042 DOI: 10.1302/0301-620x.94b8.28717] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The debate whether to use cemented or uncemented components in primary total hip replacement (THR) has not yet been considered with reference to the cost implications to the National Health Service. We obtained the number of cemented and uncemented components implanted in 2009 from the National Joint Registry for England and Wales. The cost of each component was established. The initial financial saving if all were cemented was then calculated. Subsequently the five-year rates of revision for each type of component were reviewed and the predicted number of revisions at five years for the actual components used was compared with the predicted number of revisions for a cemented THR. This was then multiplied by the mean cost of revision surgery to provide an indication of the savings over the first five years if all primary THRs were cemented. The saving at primary THR was calculated to be £10 million with an additional saving during the first five years of between £5 million and £8.5 million. The use of cemented components in routine primary THR in the NHS as a whole can be justified on a financial level but we recognise individual patient factors must be considered when deciding which components to use.
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Affiliation(s)
- E J Griffiths
- West Suffolk NHS Trust, Hardwick Lane, Bury St Edmunds, Suffolk IP33 2QZ, UK.
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Early failure of a non-cemented femoral stem after minimal-invasive total hip arthroplasty: cause analysis and classification. Musculoskelet Surg 2012; 98:77-80. [PMID: 22562648 DOI: 10.1007/s12306-012-0202-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 04/14/2012] [Indexed: 10/28/2022]
Abstract
In this paper, we present a 77-year-old female patient with an early failure of a non-cemented femoral stem 6 months after implantation. We evaluate possible reasons for the implant failure in our case against the literature. Risk factors for stem failure include a BMI >30, varus implantation, a high femoral canal cortex ratio, and a small implant. It should be distinguished between modular and non-modular stems as well as cemented and non-cemented. Early failure would be <1 year postoperatively, late failure >1 year postoperatively. A classification of stem failure differentiating time and cause is suggested as this seems to be missing in the literature.
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28
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Efe T, Schmitt J. Analyses of prosthesis stem failures in noncemented modular hip revision prostheses. J Arthroplasty 2011; 26:665.e7-12. [PMID: 20634038 DOI: 10.1016/j.arth.2010.05.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 04/17/2010] [Accepted: 05/19/2010] [Indexed: 02/01/2023] Open
Abstract
In recent years, hip prosthesis stem revision by means of modular revision systems has reached an essential role in revision prosthetics. It is an extremely successful technique. Reports about mechanical failure in nonmodular revision stems have already been published. This complication is rare, but feared. We report about mechanical failure of four non-cemented modular revision stems over a period of 28 months. All failures became clinically apparent because of severe inguinal or thigh pain and were confirmed by conventional x-ray imaging. All stem failures occurred just below the interface between prosthesis stem and neck, which is a biomechanically stressed area. Distal of the failure, all stems were still firmly fixed. In all cases, there was obvious evidence of loosening at the proximal component. Metallographic and energy-dispensive x-ray analysis of one stem showed a fatigue fracture due to dynamic stress. If new pain arises after revision surgery with modular non-cemented prosthesis systems, the possibility of an implant failure should be kept in mind. Patients should be informed accordingly about the risk of implant failure.
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Affiliation(s)
- Turgay Efe
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Germany
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29
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Unnanuntana A, Chen DX, Unnanuntana A, Wright TM. Trunnion fracture of the anatomic medullary locking a plus femoral component. J Arthroplasty 2011; 26:504.e13-6. [PMID: 20570100 DOI: 10.1016/j.arth.2010.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Accepted: 03/26/2010] [Indexed: 02/01/2023] Open
Abstract
Fracture of the neck of the femoral component after total hip arthroplasty is an infrequent complication. We present a report of 2 cases of trunnion fractures of fully porous-coated femoral stems (AML A Plus, DePuy International, Leeds, England), which had been implanted for 6 and 7 years after the index procedures. In both cases, failure emanated from a region where the trunnion had been intentionally grooved; and in both cases, the diameter of the trunnion was small, and evidence of corrosion contributing to the initiation of the failure was noted. Although this is the first report of trunnion fractures in this particular implant design, a close monitoring of prostheses with this specific trunnion should be considered. In addition, further analysis of clinical results and complications with this implant is warranted.
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Affiliation(s)
- Aasis Unnanuntana
- Department of Orthopaedic Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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30
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Revision hip arthroplasty with a short femoral component in fractured hydroxyapatite fully coated femoral stem. J Arthroplasty 2010; 25:1168.e13-6. [PMID: 19729273 DOI: 10.1016/j.arth.2009.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 06/24/2009] [Indexed: 02/01/2023] Open
Abstract
We describe a case of a fractured femoral component in a hydroxyapatite-coated cementless total hip arthroplasty that was revised using a prosthesis with circumferential proximal metaphyseal support and a lateral flare, with a short femoral stem. This type of prosthesis allows for revision, thus, avoiding the removal of the distal part of the previous prosthesis well bonded to the bone. This makes the revision arthroplasty easier and the patient's recovery quicker.
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31
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Choi D, Park Y, Yoon YS, Masri BA. In vitro measurement of interface micromotion and crack in cemented total hip arthroplasty systems with different surface roughness. Clin Biomech (Bristol, Avon) 2010; 25:50-5. [PMID: 19744754 DOI: 10.1016/j.clinbiomech.2009.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 08/12/2009] [Accepted: 08/12/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cemented stems with various surface roughnesses are used in total hip arthroplasty. However, it is not clear how the surface roughness of the stem affects the longevity of the implant. In this study, we investigated the effect of the stem roughness on the micromotion at the bone-cement and cement-implant interface and investigated cracks in the cement layer through in vitro measurement. METHODS Stems with the same shape and material but with different surface roughness (polished with Ra=0.05 microm and matte-finished with Ra=0.83 microm) were tested to measure the interface micromotion using custom-made sensors. The stems were implanted in five paired cadaver femurs and cyclic loading was applied to the femoral head to measure the interface micromotion. After loading, we measured the crack length and calculated the crack length density at the cement layer. FINDINGS The difference in the interface micromotion between the polished stem and the rough stem was not significant except at the distal region of the cement-bone interface. More cracks were found at the distal region of the polished stem than at the rough stem. The magnitude of the cement crack length density did not correlate with the interface micromotion. INTERPRETATION The results showed that the difference in the roughness between the polished and matte finishes did not significantly affect the micromotion and crack of the interface. However, more cement wear particles were expected in the matte-finished stem.
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Affiliation(s)
- Donok Choi
- Department of Mechanical Engineering, KAIST, Daejeon, 305-701, Republic of Korea
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32
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Landa J, Benke M, Dayan A, Pereira G, Di Cesare PE. Fracture of fully coated echelon femoral stems in revision total hip arthroplasty. J Arthroplasty 2009; 24:322.e13-8. [PMID: 19159839 DOI: 10.1016/j.arth.2007.12.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 12/12/2007] [Indexed: 02/01/2023] Open
Abstract
Three cases of fractured uncemented, fully porous Echelon femoral stems (Smith & Nephew, Memphis, Tenn) are examined. Fracture of these components, an uncommon complication of revision hip surgery, is thought to result from cantilever bending after distal bony ingrowth. The stems in these cases fractured at 11, 22, and 28 months after revision surgery. Risk factors include increased body weight, excessive activity, an undersized stem, varus alignment, inadequate proximal femoral bone stock, and metallurgic defects. Extraction can be difficult and is often accomplished with the use of multiple trephines or via tamping through a distal cortical window.
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Affiliation(s)
- Joshua Landa
- NYU Hospital for Joint Diseases Department of Orthopaedic Surgery, New York, New York, USA
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33
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Lam LO, Stoffel K, Kop A, Swarts E. Catastrophic failure of 4 cobalt-alloy Omnifit hip arthroplasty femoral components. Acta Orthop 2008; 79:18-21. [PMID: 18283567 DOI: 10.1080/17453670710014707] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Femoral component neck fracture is an uncommon type of failure in total hip arthroplasty. We present a report on 4 retrieved cobalt-chrome femoral components that fractured at the neck, where we investigated the mechanisms of failure. METHODS The 4 retrieved implants were analyzed with regard to their macro- and microstructures and the fracture surfaces were examined using electron microscopy. The medical record of each patient was also examined for any history of complications prior to failure of the implant. RESULTS These fractures occurred immediately adjacent to the base of the modular head. Skirted modular heads were used in 3 of the 4 failed components. This constructs promotes corrosion. Cyclic fatigue-loading in combination with the material factors of course grain microstructure and extensive carbide precipitation along the grain boundaries were also identified as the cause of implant failure. INTERPRETATION Our findings suggest that a solution annealing step could be introduced into the manufacturing process to improve the microstructure of the cobalt chrome alloy. We also advise caution in using a skirted modular head in combination with a device of known suboptimum microstructure, for a greater margin of safety.
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Affiliation(s)
- Li-On Lam
- Fremantle Orthopaedic Unit, University of Western Australia, Fremantle Hospital, Western Australia, Australia
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34
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Fractures of modern high nitrogen stainless steel cemented stems: cause, mechanism, and avoidance in 14 cases. J Arthroplasty 2008; 23:188-96. [PMID: 18280411 DOI: 10.1016/j.arth.2006.12.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 12/10/2006] [Indexed: 02/01/2023] Open
Abstract
We present 14 cases of fracture of modern, high-nitrogen, stainless steel stems. Our clinical and radiological data suggest that heavy patients with small stems and poor proximal support are at risk for fracturing their implants. "Champagne-glass" canals can lead to the use of smaller stems often placed in varus, which can lead to cantilever bending and fatigue failure in the distal half of the stem. Metallurgical assessment of the retrieved high-nitrogen, stainless steel stems reveals microstructural inconsistencies that may contribute to their failure. Based on our findings, careful consideration and attention to technique is required when using stainless steel stems in patients with high body mass index or high weight. Technique is particularly important in femurs with champagne-glass canals.
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35
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Wroblewski BM, Siney PD, Fleming PA. Increasing patients' body mass. Are the criteria for testing stemmed femoral components in total hip arthroplasty still valid? Proc Inst Mech Eng H 2008; 221:959-61. [PMID: 18161256 DOI: 10.1243/09544119jeim305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The increasing incidence of obesity in the population is a topic of current interest. This trend is reflected in patients undergoing primary Charnley hip replacement. Over a 21 year period from January 1986 to October 2006, during which 6910 primary operations were performed, the body mass of patients increased at a mean rate of 0.48 kg/year. The findings suggest that the test criteria for the endurance of stemmed femoral components be modified. The maximum load should be increased from 2.3 kN to 2.5 kN to reflect patients' increasing weight. The duration of the test should be increased from 5 x 10(6) cycles during which the 'femoral component shall not fracture' to 10 x 10(6) cycles in order to reflect not only the patients' activity level but also the 4-11 year period at risk for stem fracture, and so 'reflect developing clinical experience'.
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Affiliation(s)
- B M Wroblewski
- Wrightington Hospital, The John Charnley Research Institute, Hall Lane, Appley Bridge, Wigan, Lancashire, WN6 9EP, UK
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36
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Swarts E, Kop A, Jones N, Keogh C, Miller S, Yates P. Microstructural features in fractured high nitrogen stainless steel hip prostheses: A retrieval study of polished, tapered femoral stems. J Biomed Mater Res A 2008; 84:753-60. [PMID: 17635035 DOI: 10.1002/jbm.a.31497] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Six fractured high nitrogen stainless steel (HNSS), polished, tapered hip stems have been reviewed for analysis. Clinical data suggests that poor proximal support (loosening), varus positioning, and canal morphology are implicated in the failure of these stems. Metallurgical assessment reveals a number of microstructural deficiencies contributing to failure. Of significance is poor grain homogeneity and larger grain size near the surface of the fractured stems. It appears some polished, tapered HNSS stems are at risk when combinations of these clinical and metallurgical features occur. As the control of grain size, microstructural uniformity, and inclusion content are critical for optimum mechanical performance, it is important the manufacturers review processing methods to further minimize the risk of component failure.
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Affiliation(s)
- Eric Swarts
- Department of Medical Engineering and Physics, Royal Perth Hospital, Wellington St., Perth 6000, Western Australia, Australia.
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37
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Mullins MM, Norbury W, Dowell JK, Heywood-Waddington M. Thirty-year results of a prospective study of Charnley total hip arthroplasty by the posterior approach. J Arthroplasty 2007; 22:833-9. [PMID: 17826273 DOI: 10.1016/j.arth.2006.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2005] [Revised: 07/09/2006] [Accepted: 10/02/2006] [Indexed: 02/01/2023] Open
Abstract
We present the results of 228 consecutive Charnley low friction hip arthroplasties, performed in 193 patients, between July 1972 and December 1976. Unusually for this time, all hips were inserted by the posterior approach without a trochanteric osteotomy. All patients were enrolled into a prospective study; both preoperative and postoperative clinical and radiologic findings were recorded. This series was independently reviewed in 1985 (Atrah SGK. Long-term follow-up of Charnley total hip replacement through posterior approach. MSc thesis, University of London, 1987) and again in 2002. The preoperative and perioperative findings were similar to contemporary series. Implant positioning was also assessed. Because of our stable population, only 2 patients were lost to follow-up. Our survivorship results show a 10-year survival of 93% deteriorating to a 30-year survival of 73% (+/-6.1). The survivors were assessed radiologically and scored clinically using the Merle d'Aubigné-Postel score with a mean value of 12. The reason for revision was also recorded. These results are comparable to other studies and justify the use of the posterior approach.
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Affiliation(s)
- Mark M Mullins
- Broomfield Hospital, Department of Orthopaedics, Broomfield, Chelmsford, CM1 7ET Essex, UK
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38
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Maris I, Darmanis S, Kytopoulos V, Economakis A, Kazakos K. Mechanical failure of a Thompson's hemiarthoplasty stem 28 years post-implantation: an investigation with electron microscopy. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2007; 18:1135-9. [PMID: 17268876 DOI: 10.1007/s10856-006-0113-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 02/09/2006] [Indexed: 05/13/2023]
Abstract
Tauhe authors would like to report a mechanical failure of a Thompson's prosthesis, 28 years post-implantation. A detailed examination of the specimen revealed no defects in the prosthesis and a dominating 'brittle component' fracture of the stem. In this context the detailed fractographic study by scanning electron microscopy (SEM) revealed no detrimental manufactural defects that may have produced microcracks and consequently risked initiating the fracture propagation. In contrast, the fracture was mainly a fatigue one with a mixed mode of microscopic trans- and intergranular crack propagation. To the best of our knowledge, such a mechanism of implant failure in a cementless stem has never before reached 28 years neither in a Thompson's nor any other type of prosthesis, and in the already reported case, it exceeded 30 years [N. Wolson and J. P. Waadell, Can. J. Surg. 38(6) (1995) 542], however the stem's ultrastructure has never been investigated under electron microscopy, which arguably can provide a useful assessment of a fatigue fracture. Tauhe authors introduce the question of revising our standards when evaluating the newly designed and expensive implants and propose re-focusing on surgical technique, rather than purely on implant properties.
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Affiliation(s)
- Ioannis Maris
- Department of Orthopaedics and Trauma, Hellenic Red Cross Hospital, Athens, Greece
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39
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Wedemeyer C, Russe K, von Knoch M, Saxler G. [Endosteal reaction in the region surrounding the stem of a cement-free prosthesis. An early radiological sign of imminent fracture of the femoral shaft?]. Unfallchirurg 2006; 110:75-7. [PMID: 17058057 DOI: 10.1007/s00113-006-1171-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Periprosthetic fractures are familiar complications after total hip arthroplasty and have often been reported in the literature. The most frequent localization of such fractures is the middle third of the shaft. In the case described here a minor trauma resulted in a periprosthetic fracture with fracture of the femur and of the femoral component of a Lord prosthesis. A radiograph taken prior to trauma showed an endosteal reaction at the level at which the fracture later occurred. This might have been an indication that the stem of the prosthesis was already broken; had this radiological sign been correctly interpreted, it is possible that the fracture could have been avoided.
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Affiliation(s)
- C Wedemeyer
- Klinik für Orthopädie, Universität Duisburg-Essen im Ev. Krankenhaus Essen-Werden, 45329 Essen.
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40
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Della Valle AG, Becksaç B, Anderson J, Wright T, Nestor B, Pellicci PM, Salvati EA. Late fatigue fracture of a modern cemented [corrected] cobalt chrome stem for total hip arthroplasty: a report of 10 cases. J Arthroplasty 2005; 20:1084-8. [PMID: 16376269 DOI: 10.1016/j.arth.2005.03.038] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
We report 10 fatigue fractures of a modern, cemented, cobalt chromium alloy stem (Osteonics Omnifit) for total hip arthroplasty occurring between 1995 and 2004. The primary total hip arthroplasties had been performed between 1989 and 1996. The average age at the time of surgery was 54 years (range, 34-70 years), and the average body mass index was 29 (range, 20-38). The time in situ of the prosthesis at the time of fracture averaged 8 years (range, 4-12 years). Intermediate follow-up radiographs before the fracture were available in 7 cases, all of which demonstrated loss of calcar support. Scanning electron microscopy of the fracture surfaces in 3 of the components showed porosity near the initiation site. Metallography of polished and etched cross sections near the fracture surface revealed large grain size. In the presence of a spontaneous onset of thigh pain at intermediate follow-up in patients with this stem, particularly if associated with loss of calcar support, a fatigue fracture should be considered.
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41
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Crowninshield RD, Maloney WJ, Wentz DH, Levine DL. The role of proximal femoral support in stress development within hip prostheses. Clin Orthop Relat Res 2004:176-80. [PMID: 15057094 DOI: 10.1097/00003086-200403000-00024] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Bone remodeling commonly associated with implant loosening may require revision total hip replacement when there is substantial proximal femoral bone loss. Additionally, the surgical exposure required to remove primary implants may alter the proximal femur's structure. As a result, in many revision hip situations the proximal femur provides compromised support for the revision femoral component. Stress analyses of the proximal femur with extensively porous-coated prosthetic femoral components show that proximomedial femoral bone loss, ununited femoral osteotomy, and periprosthetic fracture can result in significant elevation of stress within revision prosthetic components. The first principal stress within prosthetic components can, in proximal bone loss conditions, be elevated significantly above a revision prostheses' fatigue strength. Loss of proximomedial bone is predicted to increase stress within a revision component by as much as 82%. An unhealed transverse femoral fracture or osteotomy is predicted to more than double the stress within a revision femoral component. In revision total hip replacement, efforts directed toward the restoration of proximal femoral bone and the use of larger prostheses may contribute to avoiding prostheses fatigue fracture. Similarly, protected weightbearing in patients with ununited femoral osteotomies and periprosthetic fractures may be important to preventing prosthetic fracture.
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42
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Macdonald W, Carlsson LV, Gathercole N, Jacobsson CM. Fatigue testing of a proximal femoral hip component. Proc Inst Mech Eng H 2003; 217:137-45. [PMID: 12666781 DOI: 10.1243/09544110360579358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Gothenburg Osseointegrated Titanium (GOT) implant is a novel total hip replacement including a metaphyseal loading proximal femoral component fixed in the retained femoral neck. Endurance testing was performed under conditions analogous to ISO 7206-4: 1989. The cement-free implant is not fixed distally within the intramedullary canal, so distal embedding (as specified in the standard) would have been unrealistic. Instead glass-fibre-reinforced epoxy (GFRE) bushings were used to model reduced bone support mid-length at the medial cortex and distally at the lateral cortex. Such support simulated proximal bone loss, realistically reproducing the effect of osteolysis or fixation failure. Under such conditions the component survived unbroken for 10 million cycles at 3.0 kN peak load.
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Affiliation(s)
- W Macdonald
- Department of Biomaterials Research, Institute for Surgical Sciences, University of Gothenburg, Sweden
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43
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Kishida Y, Sugano N, Ohzono K, Sakai T, Nishii T, Yoshikawa H. Stem fracture of the cementless spongy metal Lübeck hip prosthesis. J Arthroplasty 2002; 17:1021-7. [PMID: 12478513 DOI: 10.1054/arth.2002.35822] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
We performed 204 cementless total hip arthroplasties using a fully porous stem made of a cast cobalt-chrome-molybdenum alloy. Five stems fractured at the middle part. Champagne-fluted canals (P<.0001) and low canal fillings 1 cm below the lesser trochanter (P =.02) significantly correlated with stem fractures. Subsequent surgery revealed that all of the proximal parts were surrounded by fibrous tissue, and the distal parts showed bone ingrowth. Numerous voids were present close to the surface of the implant body. The core diameters of the fractured stems were 4 to 5 mm. The fractures may be attributed to the combination of the lack of proximal support, a champagne-fluted canal, the fully porous stem made of a cast cobalt-chrome-molybdenum alloy, and the narrow dimension of the stem core.
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Affiliation(s)
- Yuki Kishida
- Department of Orthopaedic Surgery, Osaka University Medical School, Suita, Osaka, Japan.
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44
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Wroblewski BM, Siney PD, Fleming PA. Triple taper polished cemented stem in total hip arthroplasty: rationale for the design, surgical technique, and 7 years of clinical experience. J Arthroplasty 2001; 16:37-41. [PMID: 11742449 DOI: 10.1054/arth.2001.28374] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Successful long-term clinical results with the Charnley low-friction torque arthroplasty have identified proximal femoral strain shielding as a long-term problem to be addressed. The problem has arisen because of the load transfer by a distally supported stem that is no longer subject to fracture. To overcome this problem and improve proximal load transfer to the femur, a continuous triple-tapered stem--the C stem--was designed. This article describes the first 500 primary hip arthroplasties at a mean follow-up of 3 years, 5 months (range, 1-7 years). There have been no revisions for aseptic stem loosening, and no stem is considered to be at risk for loosening. In 20% of cases, there was subjective radiologic improvement of the bone-cement interface.
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Affiliation(s)
- B M Wroblewski
- Department of Orthopaedic Biomechanics, The John Charnley Research Institute, Wrightington Hospital, Nr. Wigan, United Kingdom
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45
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Norman TL, Thyagarajan G, Saligrama VC, Gruen TA, Blaha JD. Stem surface roughness alters creep induced subsidence and 'taper-lock' in a cemented femoral hip prosthesis. J Biomech 2001; 34:1325-33. [PMID: 11522312 DOI: 10.1016/s0021-9290(01)00085-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The clinical success of polished tapered stems has been widely reported in numerous long term studies. The mechanical environment that exists for polished tapered stems, however, is not fully understood. In this investigation, a collarless, tapered femoral total hip stem with an unsupported distal tip was evaluated using a 'physiological' three-dimensional (3D) finite element analysis. It was hypothesized that stem-cement interface friction, which alters the magnitude and orientation of the cement mantle stress, would subsequently influence stem 'taper-lock' and viscoelastic relaxation of bone cement stresses. The hypothesis that creep-induced subsidence would result in increases to stem-cement normal (radial) interface stresses was also examined. Utilizing a viscoelastic material model for the bone cement in the analysis, three different stem-cement interface conditions were considered: debonded stem with zero friction coefficient (mu=0) (frictionless), debonded stem with stem-cement interface friction (mu=0.22) ('smooth' or polished) and a completely bonded stem ('rough'). Stem roughness had a profound influence on cement mantle stress, stem subsidence and cement mantle stress relaxation over the 24-h test period. The frictionless and smooth tapered stems generated compressive normal stress at the stem-cement interface creating a mechanical environment indicative of 'taper-lock'. The normal stress increased with decreasing stem-cement interface friction but decreased proximally with time and stem subsidence. Stem subsidence also increased with decreasing stem-cement interface friction. We conclude that polished stems have a greater potential to develop 'taper-lock' fixation than do rough stems. However, subsidence is not an important determinant of the maintenance of 'taper-lock'. Rather subsidence is a function of stem-cement interface friction and bone cement creep.
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Affiliation(s)
- T L Norman
- Department of Mechanical and Aerospace Engineering, West Virginia University, Morgantown, WV 26506-6106, USA.
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46
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Chang YS, Gu HO, Kobayashi M, Oka M. Influence of various structure treatments on histological fixation of titanium implants. J Arthroplasty 1998; 13:816-25. [PMID: 9802671 DOI: 10.1016/s0883-5403(98)90037-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
In this study, three types of titanium test pieces were manufactured with different surfaces and implanted into dog femoral condyles, and tissue response was assessed histologically and radiographically for 24 weeks thereafter. The study confirmed that thickening of lamellar bone could be observed around titanium plasma spray-coated titanium alloy implants 24 weeks after implantation, whereas thick fibrous tissue surrounded by corticalized bone formed around those made of smooth-sided titanium alloy. With an implant made of an artificial osteochondral composite material, thickening of ingrown trabeculae could be observed as early as 4 weeks, and abundant bone growth into the titanium fiber mesh continued to increased with time. This bone ingrowth resulted in the complete integration of this composite device implant and the host bone. Our findings suggest that cell response to the various implants is quite different, even though the implants were made of the same kind of material. The implants with the open-pore structure has great significance in the ideal fixation between the implants and the viable bone.
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Affiliation(s)
- Y S Chang
- Institute for Frontier Medical Sciences, Kyoto University, Japan
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47
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Devitt A, O'Sullivan T, Quinlan W. 16- to 25-year follow-up study of cemented arthroplasty of the hip in patients aged 50 years or younger. J Arthroplasty 1997; 12:479-89. [PMID: 9268786 DOI: 10.1016/s0883-5403(97)90169-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The clinical outcome of the cemented Charnley hip arthroplasty at follow-up periods of 16-25 years was evaluated retrospectively in patients aged 50 years or younger. One hundred thirty-two of a total of 167 hip arthroplasties were studied. The overall probability of survival of the implant at 20 years was 75% Survival of those with rheumatoid disease was 80% compared with 64% for those with osteoarthritis. Female sex was associated with a better prognosis. Accelerated wear was associated with decreased survival of the prosthesis. Varus orientation of the femoral component significantly influenced failure (P < .01). Radiographic loosening of the acetabular component was well tolerated, but loosening of the femoral component was significantly associated with pain (P = .01).
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Affiliation(s)
- A Devitt
- Cappagh Orthopaedic Hospital, Dublin, Ireland
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48
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Berger R, Fletcher F, Donaldson T, Wasielewski R, Peterson M, Rubash H. Dynamic test to diagnose loose uncemented femoral total hip components. Clin Orthop Relat Res 1996:115-23. [PMID: 8804281 DOI: 10.1097/00003086-199609000-00014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A new computed tomographic rotation study was developed to determine the stability of uncemented femoral components after total hip arthroplasty. The computed tomographic rotation study measures femoral component version with the leg in maximum external and internal rotation. The component is considered rotationally unstable, and thus loose, if these angles differ by more than 2 degrees. The results of the computed tomographic rotation study were confirmed with intraoperative inspection in 50 patients: 13 patients (Group A) with definite radiographic loosening, 22 patients (Group B) with equivocal radiographic loosening, and 15 patients (Group C) with documented stability. The results of the computed tomographic rotation study agreed with intraoperative findings for all patients in Groups A and C, and 20 of 22 patients in Group B (1 false negative and 1 false positive). Statistical analysis of Group B showed that the computed tomographic rotation study had a sensitivity of 91.6% and a specificity of 90.0%. The positive predictive value was 91.6%. These results indicate that the computed tomographic rotation study can supplement equivocal radiographic findings in assessing loosening of an uncemented femoral component.
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Affiliation(s)
- R Berger
- University of Pittsburgh, PA, USA
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49
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O'Connor DO, Burke DW, Jasty M, Sedlacek RC, Harris WH. In vitro measurement of strain in the bone cement surrounding the femoral component of total hip replacements during simulated gait and stair-climbing. J Orthop Res 1996; 14:769-77. [PMID: 8893771 DOI: 10.1002/jor.1100140514] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The strains in the cement mantle surrounding the cemented femoral component of a total hip replacement were measured in vitro, using strain gauges embedded within the cement mantle adjacent to the femoral component in femurs from cadavers under physiologic loads simulating both single-limb stance and stair-climbing. Cement strains in the most proximal portion of the cement mantle were measured with and without full contact of the collar of the femoral stem on the cortex of the medial portion of the femoral neck during both loading conditions. To our knowledge, these are the first studies to contrast by direct measurement the strain profile in the cement mantle of a cemented femoral component under simulated stair-climbing with that occurring under simulated single-limb stance. They extend the findings from finite element analyses and from clinical specimens retrieved at autopsy in identifying those regions of the cement mantle most likely to fail. At two specific foci, the magnitude of the strain in the cement mantle approaches values that could lead to early fatigue failure of the cement. The two regions in which the strains were highest (greater than 1,000 microstrain) were the most proximal portions of the cement mantle and near the tip of the femoral component. Although these two regions are recognized areas of high strain and also common sites of cement debonding and cement mantle failure, the strain-gauge studies showed that the magnitude of cement strains in the proximal portion of the cement mantle were highest during stair-climbing; in contrast, high strains at the tip region occurred in both gait and stair-climbing. Contact between the collar and the medial portion of the femoral neck reduced the strain in the proximal portion of the cement mantle not only in single-limb stance but in stair-climbing as well. The level of strain recorded in these studies for a simulated person weighing 115 pounds (52 kg) could lead to cement fracture during extended in vivo service life of a cemented femoral component, from either single-limb stance or stair-climbing. This risk would be increased if a void or defect existed in the cement mantle at these sites. Moreover, the increase in strain in the cement mantle was linear with increases in body weight between 100 and 200 pounds (45 and 91 kg) of spinal load, indicating that strains in a heavy patient could readily exceed the fatigue limit of the cement, particularly if a stress riser such as a pore in the cement or a sharp corner of the prosthesis were present. These data reemphasize the need to continue efforts to develop methods to strengthen bone cement and to reduce those factors that increase the strain in the cement mantle of cemented femoral components of total hip arthroplasty, particularly proximally and near the tip.
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Affiliation(s)
- D O O'Connor
- Orthopaedic Biomechanics Laboratory, Massachusetts General Hospital, Boston 02114, USA
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50
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Norman TL, Saligrama VC, Hustosky KT, Gruen TA, Blaha JD. Axisymmetric finite element analysis of a debonded total hip stem with an unsupported distal tip. J Biomech Eng 1996; 118:399-404. [PMID: 8872263 DOI: 10.1115/1.2796023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A tapered femoral total hip stem with a debonded stem-cement interface and an unsupported distal tip subjected to constant axial load was evaluated using two-dimensional (2D) axisymmetric finite element analysis. The analysis was performed to test if the mechanical condition suggest that a "taper-lock" with a debonded viscoelastic bone cement might be an alternative approach to cement fixation of stem type cemented hip prosthesis. Effect of stem-cement interface conditions (bonded, debonded with and without friction) and viscoelastic response (creep and relaxation) of acrylic bone cement on cement mantle stresses and axial displacement of the stem was also investigated. Stem debonding with friction increased maximum cement von Mises stress by approximately 50 percent when compared to the bonded stem. Of the stress components in the cement mantle, radial stresses were compressive and hoop stresses were tensile and were indicative of mechanical taper-lock. Cement mantle stress, creep and stress relaxation and stem displacement increased with increasing load level and with decreasing stem-cement interface friction. Stress relaxation occur predominately in tensile hoop stress and decreased from 1 to 46 percent over the conditions considered. Stem displacement due to cement mantle creep ranged from 614 microns to 1.3 microns in 24 hours depending upon interface conditions and load level.
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Affiliation(s)
- T L Norman
- Department of Mechanical and Aerospace Engineering, Musculoskeletal Research Center, West Virginia University, Morgantown 26506-9196, USA
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