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Leiss F, Goetz JS, Schindler M, Reinhard J, Müller K, Grifka J, Greimel F, Meyer M. Influence of bone mineral density on femoral stem subsidence after cementless THA. Arch Orthop Trauma Surg 2024; 144:451-458. [PMID: 37578658 DOI: 10.1007/s00402-023-05006-6] [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: 01/09/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Femoral stem subsidence can lead to aseptic loosening after total hip arthroplasty (THA). Low bone mineral density (BMD) is a risk factor for stem subsidence as it can affect the initial stability and osteointegration. We evaluated whether reduced bone mineral density is related to higher subsidence of the femoral stem after primary cementless THA with enhanced recovery rehabilitation. METHODS 79 patients who had undergone primary cementless THA with enhanced recovery rehabilitation were analyzed retrospectively. Subsidence of the femoral stem was measured on standing pelvic anterior-posterior radiographs after 4-6 weeks and one year. Patient individual risk factors for stem subsidence (stem size, canal flare index, canal fill ratio, body mass index (BMI), demographic data) were correlated. Dual X-ray absorptiometry (DXA) scans were performed of the formal neck and the lumbar spine including the calculation of T-score and Z-score. Patient-reported outcome measures were evaluated 12 months postoperatively. RESULTS Stem subsidence appeared regardless of BMD (overall collective 2.3 ± 1.64 mm). Measure of subsidence was even higher in patients with normal BMD (2.8 ± 1.7 mm vs. 2.0 ± 1.5 mm, p = 0.05). High BMI was correlated with increased stem subsidence (p = 0.015). Subsidence had no impact on improvement of patient-related outcome measures (WOMAC, EQ-5D-5L and EQ-VAS) after THA. Patients with low BMD reported lower quality of life 12 month postoperatively compared to patients with normal BMD (EQ-5D-5L 0.82 vs. 0.91, p = 0.03). CONCLUSION Stable fixation of a cementless stem succeeds also in patients with reduced BMD. Regarding stem subsidence, enhanced recovery rehabilitation can be safely applied in patients with low BMD.
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Affiliation(s)
- Franziska Leiss
- Department of Orthopedic Surgery, Asklepios Klinikum Bad Abbach, Regensburg University Medical Center, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany.
| | - Julia Sabrina Goetz
- Department of Orthopedic Surgery, Asklepios Klinikum Bad Abbach, Regensburg University Medical Center, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Melanie Schindler
- Department of Orthopedic Surgery, Asklepios Klinikum Bad Abbach, Regensburg University Medical Center, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Jan Reinhard
- Department of Orthopedic Surgery, Asklepios Klinikum Bad Abbach, Regensburg University Medical Center, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Joachim Grifka
- Department of Orthopedic Surgery, Asklepios Klinikum Bad Abbach, Regensburg University Medical Center, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Felix Greimel
- Department of Orthopedic Surgery, Asklepios Klinikum Bad Abbach, Regensburg University Medical Center, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Matthias Meyer
- Department of Orthopedic Surgery, Asklepios Klinikum Bad Abbach, Regensburg University Medical Center, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
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Crawford DA, Berend KR. Reduction of Periprosthetic Proximal Femur Fracture in Direct Anterior Total Hip According to Stem Design. Orthop Clin North Am 2021; 52:297-304. [PMID: 34538342 DOI: 10.1016/j.ocl.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The direct anterior approach (DAA) is gaining popularity in primary total hip arthroplasty (THA). Although DAA has demonstrated many advantages over other surgical approaches, periprosthetic femur fractures (PPFF) rates continue to be higher. Femoral stem designs that allow for easier insertion via a DAA may contribute to the higher rates of fracture seen in this approach. Certain stem designs and fixation methods may reduce the risk of PPFF via a DAA in primary THA.
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Affiliation(s)
- David A Crawford
- JIS Orthopedics, 7277 Smith's Mill Road, Suite 200, New Albany, OH 43054, USA.
| | - Keith R Berend
- JIS Orthopedics, 7277 Smith's Mill Road, Suite 200, New Albany, OH 43054, USA
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Dyreborg K, Sørensen MS, Flivik G, Solgaard S, Petersen MM. Preoperative BMD does not influence femoral stem subsidence of uncemented THA when the femoral T-score is > -2.5. Acta Orthop 2021; 92:538-543. [PMID: 33977827 PMCID: PMC8522811 DOI: 10.1080/17453674.2021.1920163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - It is believed that in uncemented primary total hip arthroplasty (THA) the anchorage of the stem is dependent on the level of bone mineral density (BMD) of the femoral bone. This is one of the reasons for the widely accepted agreement that a cemented solution should be selected for people with osteoporosis or age > 75 years. We evaluated whether preoperative BMD of the femur bone is related to femoral stem migration in uncemented THA.Patients and methods - We enrolled 62 patients (mean age 64 years (range 49-74), 34 males) scheduled for an uncemented THA. Before surgery we undertook DEXA scans of the proximal femur including calculation of the T- and Z-scores for the femoral neck. Evaluation of stem migration by radiostereometric analysis (RSA) was performed with 24 months of follow-up. In 56 patients both preoperative DEXA data and RSA data were available with 24 months of follow-up.Results - None of the patients had a T-score below -2.5. We found no statistically significant relationship between preoperative BMD and femoral stem subsidence after 3 or 24 months. When comparing the average femoral stem subsidence between 2 groups with T-score > -1 and T-score ≤ -1, respectively, we found no statistically significant difference after either 3 or 24 months when measured with RSA.Interpretation - In a cohort of people ≤ 75 years of age and with local femur T-score > -2.5 we found no relationship between preoperative BMD and postoperative femoral stem subsidence of a cementless THA.
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Affiliation(s)
- Karen Dyreborg
- Department of Orthopaedic Surgery, Rigshospitalet, København, Denmark
- Department of Hip and Knee Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
| | | | - Gunnar Flivik
- Department of Orthopaedics, Skåne University Hospital, Lund, Sweden
| | - Søren Solgaard
- Department of Hip and Knee Surgery, Herlev-Gentofte Hospital, Hellerup, Denmark
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Abstract
There is a high prevalence of osteoporosis in patients undergoing total hip arthroplasty. There are several clinically relevant questions related to the management of such cases: the effect of ageing; the initial osseointegration of implants, especially when cementless THA is used; the effect of medical osteoporosis treatment on bone-implant interface; the incidence of intraoperative and late periprosthetic fractures, and the long-term survival of both cemented and cementless total hip arthroplasty performed for proximal femoral fractures and hip osteoarthritis. A critical review of the literature is presented in an attempt to draw practical conclusions.
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Affiliation(s)
- Theofilos S Karachalios
- Orthopaedic Department, University General Hospital of Larissa, Larissa, Hellenic Republic (Greece).,School of Health Sciences, Faculty of Medicine, University of Thessalia, Biopolis Mezourlo Region, Larissa, Hellenic Republic (Greece)
| | - Antonios A Koutalos
- Orthopaedic Department, University General Hospital of Larissa, Larissa, Hellenic Republic (Greece)
| | - George A Komnos
- Orthopaedic Department, University General Hospital of Larissa, Larissa, Hellenic Republic (Greece)
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Kutzner KP, Kovacevic MP, Freitag T, Fuchs A, Reichel H, Bieger R. Influence of patient-related characteristics on early migration in calcar-guided short-stem total hip arthroplasty: a 2-year migration analysis using EBRA-FCA. J Orthop Surg Res 2016; 11:29. [PMID: 26951069 PMCID: PMC4782512 DOI: 10.1186/s13018-016-0363-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/03/2016] [Indexed: 12/15/2022] Open
Abstract
Background Short stems have gained popularity in recent years. Because of encouraging clinical results, indications have been expended from young to elderly and obese patients. However, long-term results are lacking. The purpose of this study was to evaluate the influence of gender, age, body weight, body mass index (BMI), and offset version on short-stem migration in correlation to the clinical outcome. Methods The implant migration of 202 metaphyseal-anchoring, calcar-guided short stems in 151 patients was assessed by “Einzel-Bild-Roentgen-Analyse” femoral component analysis (EBRA-FCA, femoral component analysis) in a 2-year follow-up. Full weight bearing was allowed directly after surgery. Patients were divided into groups regarding gender, age, body weight, BMI, and offset version. The Harris hip score (HHS) and satisfaction on visual analogue scale (VAS) were analyzed. Results After 2 years, mean axial subsidence of all 202 implants was 1.43 mm (standard deviation, SD 1.45 mm). A continuous reduction of initially pronounced subsidence over time could be observed. None of the stems had to be revised. Statistically significant increased rates of subsidence were seen in male (1.68 mm; SD 1.56 mm; p = 0.005) and heavy patients (1.54 mm; SD 1.48 mm; p = 0.022). No differences in implant migration were found regarding age, BMI, and different offset versions. HHS improved markedly from 45.8 (SD 15.9) to 98.1 (SD 4.7) while satisfaction on VAS improved from 1.8 (SD 2.2) to 9.7 (SD 0.9) after 2 years. Conclusions The results suggest a migration pattern with initially pronounced subsidence followed by subsequent stabilization. Male and obese patients show a slightly increased initial subsidence without any signs of sustained micromovement. No correlation was found concerning clinical results and pronounced initial subsidence above the threshold of 1.5 mm. No aseptic loosening or other signs of implant failure were seen within the observation period of 2 years. Trial registration German Clinical Trials Register, DRKS00009834.
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Affiliation(s)
- Karl Philipp Kutzner
- Department of Orthopaedic Surgery and Traumatology, St. Josefs Hospital Wiesbaden, Beethovenstr. 20, 65189, Wiesbaden, Germany.
| | - Mark Predrag Kovacevic
- Clinic of Traumatology, Hand- and Orthopaedic Surgery, HELIOS Dr. Horst Schmidt Clinic Wiesbaden, Ludwig-Erhard-Str. 100, 65199, Wiesbaden, Germany.
| | - Tobias Freitag
- Department of Orthopaedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Andreas Fuchs
- Department of Orthopaedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Heiko Reichel
- Department of Orthopaedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Ralf Bieger
- Department of Orthopaedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
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Cordero-Ampuero J, Peñalver P, Antón R, Galán M, Cordero E. Radiographic Subsidence in Asymptomatic Patients After THR Using the Furlong Active HAP Stem. HSS J 2013; 9:161-5. [PMID: 24426863 PMCID: PMC3757488 DOI: 10.1007/s11420-013-9342-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 05/12/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The short, tapered, collarless Furlong Active stem has been recently associated in the published literature with significant subsidence using Roentgen stereophotogrammetric analysis. QUESTIONS/PURPOSES The purpose of this study was to analyze the short-term radiographic subsidence in Furlong Active HAP stems and correlate the results with the age, gender, bone morphology, and bone quality of the proximal femur, stem diameter, and medullary canal filling. METHODS Sixty-five consecutive patients (70 hips) receiving the Furlong Active HAP stems were enrolled in this prospective series. The average follow-up was 2.99 ± 1.38 years. All patients were evaluated clinically using the Harris Hip Score (HHS) and radiographically for femoral stem subsidence. In addition, proximal femoral osteopenia, proximal femur morphology, and medullary canal filling were also evaluated. RESULTS The average subsidence was 2.4 mm (from 0 to 13 mm) at the end of the follow-up period. The average HHS score at the end of follow-up was 90 (range, 81-98). There was one intraoperative fracture. CONCLUSIONS Of the Furlong Active stems 61% subsided with initial weight bearing. Subsidence is higher in males, but no correlation has been found with age, stem diameter, morphology, osteopenia, or canal filling.
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Affiliation(s)
- José Cordero-Ampuero
- />Hospital Universitario La Princesa, c/ Diego de León 62, 28006 Madrid, Spain , />Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
| | - Pablo Peñalver
- />Hospital Universitario La Princesa, c/ Diego de León 62, 28006 Madrid, Spain , />Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
| | - Rodrigo Antón
- />Hospital Universitario La Princesa, c/ Diego de León 62, 28006 Madrid, Spain , />Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
| | - María Galán
- />Hospital Universitario La Princesa, c/ Diego de León 62, 28006 Madrid, Spain , />Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
| | - Enrique Cordero
- />Hospital Universitario La Princesa, c/ Diego de León 62, 28006 Madrid, Spain , />Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
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Sotereanos NG, Wohlrab D, Hofer A, Kuxhaus L, Miller MC. Subsidence in two uncemented femoral stems: An in vitro study. Proc Inst Mech Eng H 2013; 227:1067-72. [DOI: 10.1177/0954411913493877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Many aspects of the performance of different implant designs remain as open questions in total hip arthroplasty. Despite the increased survivorship of each hip replacement, the amount of bone removed during surgery remains an important factor because of the potential need for revision surgery. Given that a smaller implant will have less surface area over which to transfer load, constructs that preserve more bone stock may be susceptible to mechanical complications related to the fixation of the implant in the femur. To assess mechanical fixation, this study compared the fiber metal taper and Mayo conservative hip stems in subsidence, frontal plane rotation and failure load. After dual-energy x-ray absorptiometry scans, pairs of cadaveric femurs received implants of each type and were loaded for 10,000 cycles. The subsidence and rotation were measured. Finally, specimens were loaded to failure. The subsidence and rotation after cyclic loading were −0.73 mm and 0.1°, respectively, for the Mayo implants and −0.87 and 0.52°, respectively, for the fiber metal taper implants, but no significant differences between implant types were found. There was also no significant relationship to bone mineral density. A power analysis revealed that 914 specimens would have been required to achieve a power of 0.8.
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Affiliation(s)
| | - David Wohlrab
- Orthopädie, Martin-Luther-Universität, Halle-Wittenberg, Germany
| | - Andre Hofer
- Klinik und Poliklinik für Orthopädie, Universitätsklinikum Greifswald, Greifswald, Germany
| | - Laurel Kuxhaus
- Mechanical & Aeronautical Engineering, Clarkson University, Potsdam, NY, USA
| | - Mark Carl Miller
- Biomechanics Laboratory, Allegheny General Hospital, Pittsburgh, PA, USA
- Departments of Mechanical Engineering and Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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Moritz N, Alm JJ, Lankinen P, Mäkinen TJ, Mattila K, Aro HT. Quality of intertrochanteric cancellous bone as predictor of femoral stem RSA migration in cementless total hip arthroplasty. J Biomech 2010; 44:221-7. [PMID: 21074160 DOI: 10.1016/j.jbiomech.2010.10.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 10/12/2010] [Indexed: 01/29/2023]
Abstract
In cementless total hip arthroplasty, osteoporosis may jeopardize the achievement of immediate stability and lead to migration of anatomically shaped femoral stems. Poor quality of proximal cancellous bone per se may also affect the rate of osseointegration. In a selected group of female total hip arthroplasty patients (mean age 64 years) with unremarkable medical history, intertrochanteric cancellous bone biopsy was taken from the site of stem implantation. Local bone quality, determined by structural μCT imaging and destructive compression testing of the biopsy tissue, was used as the predictor of three-dimensional stem migration determined by radiostereometric analysis (RSA) up to 24 months. The patients exhibited major differences in mechanical properties of the intertrochanteric cancellous bone, which were closely related to the structural parameters calculated from μCT data. Unexpectedly, the major differences observed in the quality of trochanteric cancellous bone had only minor reflections in the RSA migration of the femoral stems. In statistical analysis, the μCT-based bone mineral density quartile (low, middle, high) was the only significant predictor for stem translation at 24 months (p=0.022) but only a small portion (R(2)=0.16) of the difference in translation could be explained by changes in bone mineral density quartile. None of the other parameters investigated predicted stem migration in translation or rotation. In conclusion, poor quality of intertrochanteric cancellous bone seems to contribute to the risk of implant migration less than expected. Probably also the importance of surgical preservation of intertrochanteric cancellous bone has been over-emphasized for osseointegration of cementless stem.
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Affiliation(s)
- Niko Moritz
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, University of Turku, Kiinamyllykatu 10, Turku, Finland
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