1
|
Hegde V, Harris AB, Springer BD, Khanuja HS. Cemented Stem Design in Total Hip Arthroplasty: Fixation Philosophies, Biomechanics, and an Updated Classification System. J Am Acad Orthop Surg 2024; 32:525-534. [PMID: 38626413 DOI: 10.5435/jaaos-d-23-00914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/20/2024] [Indexed: 04/18/2024] Open
Abstract
There is renewed interest in cemented femoral fixation in total hip arthroplasty in the United States, and to fully appreciate the evolution of cemented femoral stem designs, an understanding of their history and design rationale is essential. To adequately study the outcomes of modern-day designs, a comprehensive classification system is also necessary. The biomechanical principles, failure mechanisms, and clinical outcomes associated with various cemented femoral stems are described in this comprehensive review. In addition, an updated version of an existing classification system is described that incorporates the primary design characteristics which differentiate implants currently in use. In this classification, implants are categorized as taper-slip (Type I), which are subdivided by Anatomic (IA), Double-Taper (IB), and Triple-Taper (IC) with subclassification for Traditional and Line-to-Line implants. Composite beam (Type II) implants are similarly divided into Anatomic (IIA), Straight (IIB), and Wedge (IIC) with subclassification for Polished, Satin, or Roughened finish. This classification system provides a basis for comparing cemented femoral stems, thereby improving our understanding of the effect of design characteristics on survivorship to guide future advancements and improve clinical outcomes.
Collapse
Affiliation(s)
- Vishal Hegde
- From the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD (Dr. Hegde, Dr. Harris, Dr. Khanuja), and the OrthoCarolina Hip and Knee Center and Atrium Musculoskeletal Institute, Charlotte, NC (Dr. Springer)
| | | | | | | |
Collapse
|
2
|
Turnbull G, Blacklock C, Akhtar A, Dunstan E, Ballantyne JA. Experience of an anatomic femoral stem in a UK orthopaedic centre beyond 20 years of follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2155-2162. [PMID: 38565783 PMCID: PMC11101503 DOI: 10.1007/s00590-024-03901-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Increasing interest in the use of anatomical stems has developed as the prevalence of periprosthetic fractures (PPFs) continues to increase. The primary aim of this study was to determine the long-term survivorship and PPF rate of an anatomical femoral stem in a single UK centre. PATIENTS AND METHODS Between 2000 and 2002, 94 consecutive THAs were performed using the 170 mm Lubinus SP II anatomical femoral stem in our institution. Patient demographics, operative details and clinical outcomes were collected prospectively in an arthroplasty database. Patient records and national radiographic archives were reviewed finally at a mean of 21.5 years (SD 0.7) following surgery to identify occurrence of subsequent revision surgery, dislocation or periprosthetic fracture. RESULTS Mean patient age at surgery was 65.8 years (SD 12.5, 34-88 years). There were 48 women (51%). Osteoarthritis was the operative indication in 88 patients (94%). Analysis of all-cause THA failure demonstrated a survivorship of 98.5% (95% confidence interval [CI], 98.0-99.3%) at 10 years and 96.7% (94.5-98.9%) at 21 years. The 20-year stem survival for aseptic loosening was 100% with no cases of significant lysis found (lucent line > 2 mm) and no stems required revision. Patient demographics did not appear to influence risk of revision (p > 0.05). There were 2 revisions in total (2 for acetabular loosening with original stems retained). There were no PPFs identified at mean 21.5 year follow-up and 5 dislocations (5%). CONCLUSIONS The Lubinus SP II 170 mm stem demonstrated excellent survivorship and negligible PPF rates over 20 years following primary THA.
Collapse
Affiliation(s)
- G Turnbull
- National Treatment Centre Fife Orthopaedics, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, Scotland, UK.
- The Royal Infirmary of Edinburgh, 51 Little France Cres, Old Dalkeith Rd, Edinburgh, EH16 4SA, Scotland, UK.
| | - C Blacklock
- National Treatment Centre Fife Orthopaedics, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, Scotland, UK
| | - A Akhtar
- National Treatment Centre Fife Orthopaedics, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, Scotland, UK
| | - E Dunstan
- National Treatment Centre Fife Orthopaedics, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, Scotland, UK
| | - J A Ballantyne
- National Treatment Centre Fife Orthopaedics, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, Scotland, UK
| |
Collapse
|
3
|
Kristóf J, Gupta D, Szabó L, Bucsi L, Zahár Á. Outcomes of Exeter cemented total hip arthroplasty in a county hospital: survivorship of eight hundred and ninety four hips with a minimum ten-year follow up. INTERNATIONAL ORTHOPAEDICS 2024; 48:729-735. [PMID: 37914902 DOI: 10.1007/s00264-023-06026-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 10/23/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE A total of 894 hips were evaluated to describe the survivorship of Exeter cemented femoral stems and report the outcomes and complications of our 'Exeter- era', and there is no study from Central or Eastern Europe demonstrating similar results. METHODS Between January 2000 and December 2009, a total of 894 hips were included who underwent Exeter universal and V40 femoral stems with a mean follow up of 13 years. Cemented Exeter low profile polyethylene cups were used in 889 patients (99.4%) cups. Harris hip score (HHS) was used and statistical outcome measures were calculated with revision as an endpoint for aseptic loosening of the stem, aseptic loosening of any component, all-cause revision of the stem, and all-cause revision of the hip. RESULTS A total of 103 patients died and 129 (14.4%) operated hips were lost to follow-up before ten years. Out of the 662, ten stems (1.5%) were revised for aseptic loosening. Aseptic loosening of any component was the reason for revision in 43 cases (6.5%), consisting of 40 cup revisions and ten stem exchanges. Periprosthetic fracture occurred in 17 cases (1.9%) Periprosthetic joint infection occurred in 18 cases (2.01%). Three cups were exchanged for recurrent dislocation, and two stems had broken. CONCLUSION Exeter hip system has provided reproducible results across different centres worldwide, as it did in our series. Thorough surgical and cementing technique is of utmost importance for achieving these results. The cup is the weak point of the system and use of a hybrid system is worth considering.
Collapse
Affiliation(s)
- Jánvári Kristóf
- Department of Orthopaedics, Saint George University Teaching and County Hospital Centre for Musculoskeletal Surgery, Székesfehérvár, Hungary
| | - Devanshu Gupta
- Department of Orthopaedics, Saint George University Teaching and County Hospital Centre for Musculoskeletal Surgery, Székesfehérvár, Hungary.
| | - László Szabó
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
| | - László Bucsi
- Department of Orthopaedics, Saint George University Teaching and County Hospital Centre for Musculoskeletal Surgery, Székesfehérvár, Hungary
| | - Ákos Zahár
- Department of Orthopaedics, Saint George University Teaching and County Hospital Centre for Musculoskeletal Surgery, Székesfehérvár, Hungary
| |
Collapse
|
4
|
Thomsen M, van Uden M, Kretzer JP. [Current design and cement mantle thickness in hip arthroplasty : Theory and analysis of register data]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:1-10. [PMID: 37978051 DOI: 10.1007/s00132-023-04454-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND In this article, an overview and comparison of the most commonly used cemented hip stems, grouped into different stem types and cement mantle thickness, is given to see which combination performs well. METHODOLOGY Revision rates of cemented stem types were categorized from the Endoprosthesis Register-Germany, and 3‑ and 5‑year revision rates were reported and analyzed. For the research, the focus was on the Exeter, C‑Stem, MS-30, Excia, Bicontact, Charnley, Müller straight stem, Twinsys, Corail, Avenir, Quadra, and the Lubinus SP II stems. An important aspect was which stem is preferred to be implanted and which cementing technique is used with regard to the planned cement mantle thickness. In order to identify a trend in cemented hip arthroplasty, data from the Danish, Swedish, Norwegian, Swiss, New Zealand, English and Australian arthroplasty registers were also compared. RESULTS AND CONCLUSION Most countries use cemented prostheses according to the taper slip principle (Exeter, MS30, C‑Stem etc) or the composite beam (Charnley, Excia, Bicontact), which are implanted with a cement mantle thickness of 2-4 mm. However, a trend has emerged in Germany and Switzerland towards the line-to-line technique, with a planned cement mantle thickness of 1 mm (Twinsys, Corail, Avenir, Quadra), following the principle of the Müller straight stem prosthesis and the Kerboul-Charnley prosthesis, even though these are postulated to be "French paradoxes" in themselves. In the EPRD 5‑year results, the newer line-to-line prostheses seem to perform slightly worse. The best results are achieved by the "MS 30" in Germany and the "Exeter" in England. These are polished straight stems with centralizer and subsidence space at the apex with a 2-4 mm cement mantle in good cementing technique.
Collapse
Affiliation(s)
- M Thomsen
- Klinik für Orthopädie und Unfallchirurgie, Balger Str. 50, 76532, Baden-Baden, Deutschland.
| | - M van Uden
- Biomechanik, Hochschule Offenburg of applied science, Offenburg, Deutschland
| | - J P Kretzer
- Labor für Biomechanik und Implantatforschung, Orthopädische Universitätsklinik Heidelberg, Heidelberg, Deutschland
| |
Collapse
|
5
|
Moralidou M, Di Laura A, Hothi H, Henckel J, Hart AJ. Cemented or uncemented fixation: Which allows a more acceptable prosthetic femoral version in total hip arthroplasty? J Orthop Surg Res 2023; 18:948. [PMID: 38071336 PMCID: PMC10710710 DOI: 10.1186/s13018-023-04331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Three-dimensional computed-tomography (3D-CT) planning for primary Total Hip Arthroplasty (THA) typically uses the external femoral surface; as a result, it is difficult to predict the prosthetic femoral version (PFV) for uncemented femoral stems that press-fit to the internal surface of the bone. Cemented fixation allows the surgeon to adjust the version independent of the internal femoral anatomy. We aimed to better understand the effect of the fixation type on PFV. METHODS This was a case series study including a total of 95 consecutive patients (106 hips), who underwent uncemented (n = 81 hips) and cemented (n = 25 hips) primary THA using the posterior approach. The surgeon aimed for a PFV of 20°. Our primary objective was to compare PFV in both groups; our secondary objective was to evaluate the clinical outcomes. RESULTS The mean (± SD) PFV was 13° (± 9°) and 23° (± 8°) for the uncemented and cemented THA groups (P < 0.001), respectively. In the uncemented THA group, 36% of the patients had a PFV of < 10°. In the cemented THA group, this clinically important threshold dropped to 8%. Similarly, the Bland-Altman (BA) plots showed wider 95% limits of agreement for the uncemented group. Satisfactory clinical outcomes were recorded. CONCLUSION We found that the PFV was more clinically acceptable, for the posterior surgical approach, in the cemented group when compared to the uncemented group. Both THA groups reported high variability indicating the need to develop surgical tools to guide the PFV closer to the surgical target.
Collapse
Affiliation(s)
- Maria Moralidou
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Anna Di Laura
- The Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK
| | - Harry Hothi
- The Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK
| | - Johann Henckel
- The Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Alister J Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Brockley Hill, Stanmore, HA7 4LP, UK.
- Cleveland Clinic London Hospital, 33 Grosvenor Pl, London, SW1X 7HY, UK.
| |
Collapse
|
6
|
Heijnens LJ, Heyligers IC, Boonen B, Spekenbrink-Spooren A, van Haaren EH, Schotanus MG. Survival rates of anatomically shaped and tapered slip cemented femoral implants: an analysis of 76,281 femoral implants of the Dutch arthroplasty register (LROI). Hip Int 2023; 33:1035-1042. [PMID: 36536533 DOI: 10.1177/11207000221145150] [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] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In cemented total hip arthroplasty (THA) various shapes and geometries of femoral implants are in use. Collarless, polished, and tapered (CPT) implants, and anatomically shaped (AS) implants are most commonly used. Due to their different design features, this might lead to different survival outcomes. In this register-based study, overall implant survival and short-term complications of CPT and AS cemented implants were evaluated. METHODS Data of the Dutch Arthroplasty Register (LROI) were used. Cemented femoral implants, which could be classified as CPT or AS were included in this study. Implants were excluded when no classification could be made or if implanted <100 times. Survival analyses were performed using Kaplan-Meier survival analysis and multivariable Cox-proportional hazard analysis. RESULTS 76,281 cemented THAs were included. At a mean of 5.1 years follow-up (SD 3.1, range 0-12 years), the overall survival of the AS implants was higher compared with the CPT implants, with a survival, of 99.2% and 99.0% respectively (log-rank; p < 0.001). Multivariable regression analysis revealed a higher rate for revision because of loosening of the AS implants (HR 2; CI, 1.4-3.1). AS implants had a lower rate for periprosthetic fractures compared with the CPT implants (HR 0.13; CI, 0.07-0.23). CONCLUSIONS Both designs show excellent overall survival rates at short-term follow-up. There is a higher overall survival of AS implants when compared with CPT implants. Revision for implant loosening, however, was statistically significantly higher in AS implants when compared with the CPT implants.
Collapse
Affiliation(s)
- Luc Jm Heijnens
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, The Netherlands
| | - Ide C Heyligers
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, The Netherlands
- School of Health Profession Education, Faculty of Health, Medicine and Life Science, Maastricht University, The Netherlands
| | - Bert Boonen
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, The Netherlands
| | - Anneke Spekenbrink-Spooren
- Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Implantaten), 's-Hertogenbosch, The Netherlands
| | - Emil H van Haaren
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, The Netherlands
| | - Martijn Gm Schotanus
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, The Netherlands
- School of Care and Public Health Research Institute, Faculty of Health, Medicine and Life Science, Maastricht University, The Netherlands
| |
Collapse
|
7
|
Chulsomlee K, Prukviwat S, Tuntiyatorn P, Vasaruchapong S, Kulachote N, Sirisreetreerux N, Tanphiriyakun T, Chanplakorn P, Sa-Ngasoongsong P. Correlation between shape-closed femoral stem design and bone cement implantation syndrome in osteoporotic elderly femoral neck fracture undergoing cemented hip arthroplasty: A retrospective case-control study in 128 patients. Orthop Traumatol Surg Res 2023; 109:103450. [PMID: 36273503 DOI: 10.1016/j.otsr.2022.103450] [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: 09/28/2021] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bone cement implantation syndrome (BCIS) is a serious and potentially fatal complication especially in patients with osteoporotic femoral neck fracture (OFNF) undergoing cemented hip arthroplasty (CHA). Recent studies showed that the shape-closed femoral stem profile could lead to a significant increase of the intramedullary pressure during cementation and prosthesis insertion. This study aimed to (1) correlate the use of shaped-closed femoral stem and other perioperative risk factors with severe grade of BCIS grade 2 or 3: BCIS gr2/3, and (2) identify the prevalence of BCIS in the elderly patients with OFNF and treated with CHA. HYPOTHESIS Large wedge-shaped (or "shape-closed") femoral stem design would significantly associate with BCIS gr2/3 in the elderly patients who sustained OFNF and underwent CHA. PATIENTS AND METHODS A total of 128 OFNF patients, who aged over 75years and underwent CHA were retrospectively reviewed and then allocated into 2 groups: SC Group (use shape-closed femoral stem, n=40) and FC Group (use force-closed femoral stem, n=88). BCIS was grading in all patients according to Donaldson classification. Perioperative data between the patients with BCIS-gr2/3 and those with BCIS grade 0 or 1 (BCIS-gr0/1) were compared. Multiple logistic regression analysis was used to identify predictive factors for BCIS-gr2/3. RESULTS The prevalence of overall BCIS and BCIS-gr2/3 was 32.8% (n=42) and 6.2% (n=8), respectively. The total in-hospital and 1-year mortality rates were 2.3% and 4.7%, respectively. The major perioperative complication in patients with BCIS-gr2/3 was significantly higher compared to those in patients with BCIS-gr0/1 (62.5% vs. 10.0%, p=0.001). Multivariate analysis showed that age>90years (OR=9.4, 95% CI: 1.4-62.9, p=0.02), preinjury Parker mobility score<4 (OR=48.8; 95% CI: 2.7-897.2, p=0.008) and shape-closed femoral stem used (OR=19.1; 95% CI: 1.8-204.5, p=0.01) were the significant independent predictors for BCIS-gr2/3 in these patients. CONCLUSION BCIS in OFNF patients undergoing CHA is common and associates with a high major perioperative complication rate. Our initial hypothesis is validated as the patients at risk for BCIS-gr2/3 are those whose CHA procedures use a shape-closed femoral stem design and with extreme age, and having poor preinjury ambulatory status. Therefore, we recommended using cementless stem as the first option in OFNF. However, if CHA is needed, strict guideline for cement insertion should be followed with force-closed stem application to avoid the risk of BCIS-gr2/3. LEVEL OF EVIDENCE III; retrospective case-control study.
Collapse
Affiliation(s)
- Kulapat Chulsomlee
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasichol Prukviwat
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panithan Tuntiyatorn
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Satetha Vasaruchapong
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Noratep Kulachote
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Norachart Sirisreetreerux
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thiraphat Tanphiriyakun
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pongsthorn Chanplakorn
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Paphon Sa-Ngasoongsong
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
8
|
Shichman I, Oakley CT, Beaton G, Davidovitch RI, Schwarzkopf R, Rozell JC. Are we getting better at cementing femoral stems in total hip arthroplasty? A 5-year institutional trend. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04751-4. [PMID: 36593365 DOI: 10.1007/s00402-022-04751-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Femoral stem cementation provides excellent implant longevity with a low periprosthetic fracture rate among patients with compromised bone quality or abnormal anatomy. We radiologically evaluated the quality of the femoral cement mantle in patients undergoing THA to examine whether cementation quality improved with increased institutional experience. METHODS A retrospective study of 542 primary elective THAs performed using cemented stems from 2016 to 2021 at a high-volume orthopedic specialty center was conducted. Immediate post-operative anterior-posterior (AP) and lateral radiographs were evaluated to assess cement mantle quality based on the Barrack classification. Cement mantles were deemed satisfactory (Barrack A and B) or unsatisfactory (Barrack C and D). Regression was performed to identify predictors of unsatisfactory cementation quality. RESULTS The annual cemented primary THA volume increased throughout the study period from 14 cases in 2016 to 201 cases in 2021. Overall, the majority of cement mantles were deemed satisfactory; 91.7% on AP radiographs and 91.0% on lateral radiographs. Satisfactory cementation on AP radiograph achievement rates improved during the study period, which coincided with greater annual volume (p < 0.001). No association was found between posterior and direct anterior surgical approaches and satisfactory cementation quality on both AP and lateral radiographs. CONCLUSION Majority of femoral stems had satisfactory cementation quality. Higher institutional annual cemented THA volume was associated with improved cementation quality. Residency and fellowship training programs should place greater emphasis on the importance of femoral stem cementation for appropriately indicated patients. LEVEL OF EVIDENCE III, retrospective cohort study.
Collapse
Affiliation(s)
- Ittai Shichman
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, 4th Floor, New York, NY, USA.,Division of Orthopedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Christian T Oakley
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, 4th Floor, New York, NY, USA
| | - Geidily Beaton
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, 4th Floor, New York, NY, USA
| | - Roy I Davidovitch
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, 4th Floor, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, 4th Floor, New York, NY, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, 4th Floor, New York, NY, USA.
| |
Collapse
|
9
|
Mancino F, Tornberg H, Jones CW, Bucher TA, Malahias MA. The exeter cemented stem provides outstanding long-term fixation and bone load at 15 years follow-up: A systematic review and meta-analysis. J Orthop Surg (Hong Kong) 2023; 31:10225536231153232. [PMID: 36655735 DOI: 10.1177/10225536231153232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Since its introduction in 1988, the double-tapered polished Exeter cemented stem has been widely adopted in primary total hip arthroplasty (THA). Despite the results coming from the arthroplasty registries have proven great survivorship, the aim of this study was to dig deeper and describe the modes of failure of the Exeter stem at 15 years follow-up while reporting the clinical and radiographic outcomes. METHODS A search of PubMed, MEDLINE, and Embase was performed using the Preferred Reporting Items for Systematic Review and Meta-Analyses since inception of database to January 2022. A meta-analysis was performed on stem's failure rates and clinical outcomes using random effects models. Publication bias was assessed with funnel plots. RESULTS Overall, ten studies met the inclusion criteria with 2167 hips at mean 14.8 ± 4.1 years follow-up. The meta-effect estimate for revision rate for stem-related reasons was 3.8% (CI 95% 2.1-5.6, p < 0.01). The meta-effect for revision rate for stem aseptic loosening (AL) was 0.22% (CI 95% 0-0.4, p = 0.048) and for periprosthetic fracture was 0.6% (CI95% 0.3-0.9, p < 0.001). The meta effect estimate for Oxford Hip Score (OHS) at final follow-up was 32.4 (moderate; CI 95% 23.2-41.6, p <0.001) with and heterogeneity among the studies of I2 0%. Radiolucent lines were reported in 5.5% of cases, with 1.0% of cases (21 hips) reported to be progressive. CONCLUSION Current evidence suggests that the Exeter cemented stem not only has proven long-term outstanding reliability with a revision rate of 3.8%, but also incredibly low revision rates for AL (0.22%) and periprosthetic fracture (0.6%). It is suitable for a variety of indications, and the consistent radiological appearances indicate durable fixation and load transmission while being associated with a remarkably low stem-related complication rate.
Collapse
Affiliation(s)
- Fabio Mancino
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia (ORFWA), 418838Fiona Stanley Hospital, Perth, WA, Australia
| | - Haley Tornberg
- 363994Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Christopher W Jones
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia (ORFWA), 418838Fiona Stanley Hospital, Perth, WA, Australia.,Curtin University, Perth, WA, Australia
| | - Thomas A Bucher
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia (ORFWA), 418838Fiona Stanley Hospital, Perth, WA, Australia
| | - Michael-Alexander Malahias
- 3rd Orthopaedic Department, Therapis General Hospital, Athens, Greece.,Stavros Niarchos Foundation Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Division, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
10
|
Armbruster M, Paulus A. [Postoperative imaging of the hip]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:862-869. [PMID: 35904572 DOI: 10.1007/s00117-022-01050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
CLINICAL ISSUE To assess postoperative imaging of the hip joint regarding possible complications, it is indispensable to have in-depth knowledge of commonly used surgical techniques, access routes, and the implanted materials. STANDARD RADIOLOGICAL METHODS While radiography is used to evaluate the position of foreign material and to rule out periprosthetic fractures that have occurred intraoperatively, follow-up examinations might show signs of material failure, aseptic loosening, prosthesis infections, or the occurrence of heterotopic ossifications. If radiographic findings are ambiguous, computed tomography (CT) may be used to clarify findings, whereas magnetic resonance imaging (MRI) is helpful to identify intra- and periarticular soft tissue pathologies such as surgery-associated cartilage and ligament damage, muscle insufficiency, or metallosis. METHODOLOGICAL INNOVATION AND EVALUATION To guide clinical decision making in common postoperative complications, various classification systems are available, e.g., for periprosthetic fractures, aseptic loosening, or heterotopic ossification. However, the differentiation between aseptic material loosening and septic endoprosthesis infection remains challenging if based on imaging alone. PRACTICAL RECOMMENDATIONS The assessment of postoperative hip imaging should be closely linked to the respective surgical technique and the implanted foreign material, whereby different probabilities of specific complications can be derived.
Collapse
Affiliation(s)
- Marco Armbruster
- Klinik und Poliklinik für Radiologie, LMU Klinikum München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - Alexander Paulus
- Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, LMU Klinikum, Campus Großhadern, München, Deutschland
| |
Collapse
|
11
|
El-Othmani MM, Zalikha AK, Cooper HJ, Shah RP. Femoral Stem Cementation in Primary Total Hip Arthroplasty. JBJS Rev 2022; 10:01874474-202210000-00005. [PMID: 36215391 DOI: 10.2106/jbjs.rvw.22.00111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
➢ Femoral stem cementation has undergone considerable investigation since bone cement was first used in arthroplasty, leading to the evolution of modern femoral stem cementation techniques. ➢ Although there is a worldwide trend toward the use of cementless components, cemented femoral stems have shown superiority in some studies and have clear indications in specific populations. ➢ There is a large evidence base regarding cement properties, preparation, and application techniques that underlie current beliefs and practice, but considerable controversy still exists. ➢ Although the cementing process adds technical complexity to total hip arthroplasty, growing evidence supports its use in certain cohorts. As such, it is critical that orthopaedic surgeons and investigators have a thorough understanding of the fundamentals and evidence underlying modern cementation techniques.
Collapse
Affiliation(s)
- Mouhanad M El-Othmani
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York
| | - Abdul K Zalikha
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, Michigan
| | - H John Cooper
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York
| | - Roshan P Shah
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York
| |
Collapse
|
12
|
Khanuja HS, Mekkawy KL, MacMahon A, McDaniel CM, Allen DA, Moskal JT. Revisiting Cemented Femoral Fixation in Hip Arthroplasty. J Bone Joint Surg Am 2022; 104:1024-1033. [PMID: 35298444 PMCID: PMC9969348 DOI: 10.2106/jbjs.21.00853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ The primary means of femoral fixation in North America is cementless, and its use is increasing worldwide, despite registry data and recent studies showing a higher risk of periprosthetic fracture and early revision in elderly patients managed with such fixation than in those who have cemented femoral fixation. ➤ Cemented femoral stems have excellent long-term outcomes and a continued role, particularly in elderly patients. ➤ Contrary to historical concerns, recent studies have not shown an increased risk of death with cemented femoral fixation. ➤ The choice of femoral fixation method should be determined by the patient's age, comorbidities, and bone quality. ➤ We recommend considering cemented femoral fixation in patients who are >70 years old (particularly women), in those with Dorr type-C bone or a history of osteoporosis or fragility fractures, or when intraoperative broach stability cannot be obtained.
Collapse
Affiliation(s)
- Harpal S. Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Kevin L. Mekkawy
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Aoife MacMahon
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Claire M. McDaniel
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Donald A. Allen
- Department of Orthopaedic Surgery, Carilion Clinic, Roanoke, Virginia
| | - Joseph T. Moskal
- Department of Orthopaedic Surgery, Carilion Clinic, Roanoke, Virginia
| |
Collapse
|
13
|
Takegami Y, Seki T, Osawa Y, Imagama S. Comparison of periprosthetic femoral fracture torque and strain pattern of three types of femoral components in experimental model. Bone Joint Res 2022; 11:270-277. [PMID: 35514237 PMCID: PMC9130673 DOI: 10.1302/2046-3758.115.bjr-2021-0375.r2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS Periprosthetic hip fractures (PPFs) after total hip arthroplasty are difficult to treat. Therefore, it is important to identify modifiable risk factors such as stem selection to reduce the occurrence of PPFs. This study aimed to clarify differences in fracture torque, surface strain, and fracture type analysis between three different types of cemented stems. METHODS We conducted biomechanical testing of bone analogues using six cemented stems of three different types: collarless polished tapered (CPT) stem, Versys Advocate (Versys) stem, and Charnley-Marcel-Kerboull (CMK) stem. Experienced surgeons implanted each of these types of stems into six bone analogues, and the analogues were compressed and internally rotated until failure. Torque to fracture and fracture type were recorded. We also measured surface strain distribution using triaxial rosettes. RESULTS There was a significant difference in fracture torque between the three stem types (p = 0.036). Particularly, the median fracture torque for the CPT stem was significantly lower than that for the CMK stem (CPT vs CMK: 164.5 Nm vs 200.5 Nm; p = 0.046). The strain values for the CPT stem were higher than those for the other two stems at the most proximal site. The fracture pattern of the CPT and Versys stems was Vancouver type B, whereas that of the CMK stem was type C. CONCLUSION Our study suggested that the cobalt-chromium alloy material, polished surface finish, acute-square proximal form, and the absence of a collar may be associated with lower fracture torque, which may be related to PPF. Cite this article: Bone Joint Res 2022;11(5):270-277.
Collapse
Affiliation(s)
- Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taisuke Seki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Osawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
14
|
Macheras GA, Lepetsos P, Galanakos SP, Papadakis SA, Poultsides LA, Karachalios TS. Early failure of an uncemented femoral stem, as compared to two other stems with similar design, following primary total hip arthroplasty performed with direct anterior approach. Hip Int 2022; 32:166-173. [PMID: 32662662 DOI: 10.1177/1120700020940671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION An increased risk of early femoral component loosening has been reported using the direct anterior approach (DAA) compared with other common surgical approaches. However, long-term data are scarce. The purpose of this study is: (1) to determine the incidence of early femoral loosening in a high volume, single surgeon's practice utilising the DAA approach; and (2) to examine the effect of stem design and type of coating on aseptic loosening in the early and mid-term postoperative period. METHODS A retrospective review of 1650 consecutive patients (1800 hips) who underwent total hip arthroplasty (THA) using the DAA between August 2011 and December 2017 was conducted at our institution. 3 types of uncemented femoral stems (Quadra-S, Avenir, TwinSys), with similar design, but different coating, were implanted. Patients were evaluated clinically and radiologically at 4 weeks, 3 months, 1 year, and annually thereafter. RESULTS After a mean follow-up of 46.4 months, the total incidence of revision for aseptic loosening was 0.44% (n = 8). All loose stems were Quadra-S, failing to achieve osseointegration, for an overall incidence of 0.96% (p = 0.002). None of the other stems were loose. Radiolucent lines around the proximal stem portion were visible in 75 Quadra-S stems (4.1%) on radiographs taken at 1 year postoperatively and continued to deteriorate at the latest follow-up. CONCLUSIONS In this specific cohort of patients, the increased rate of femoral stem aseptic loosening was implant-related and was attributed only to a specific type of femoral stem (Quadra-S). No relation to other factors was proven suggesting that the surface characteristics of this femoral stem and the lack of bioactive coating are responsible for the observed early femoral failures. These findings should be confirmed by additional registry work and larger population sample sizes are needed to evaluate the prosthesis performance after implantation through the DAA.
Collapse
Affiliation(s)
- George A Macheras
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Athens, Greece
| | | | | | | | - Lazaros A Poultsides
- 3rd Academic Department of Orthopaedics and Trauma, Aristotle University Medical School, Thessaloniki, Greece
| | | |
Collapse
|
15
|
Hopman SR, de Windt TS, van Erp JHJ, Bekkers JEJ, de Gast A. Uncemented total hip arthroplasty; increased risk of early periprosthetic fracture requiring revision surgery in elderly females. J Orthop 2021; 25:40-44. [PMID: 33867753 DOI: 10.1016/j.jor.2021.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/12/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022] Open
Abstract
Purpose The preferred method of stem fixation in total hip arthroplasty (THA) remains debatable. Uncemented THA favors a lower rate of aseptic loosening but has an increased risk of early periprosthetic fractures (EPF). We hypothesize that routine placement of uncemented THA by experienced surgeons diminishes this EPF-risk. The purpose of this study is to investigate the effect of age, gender, ASA classification and BMI of THA performed by experienced surgeons on the risk of EPF. Methods A retrospective cohort study including all primary THAs and revision surgeries performed between 2012 and 2018. Possible predictive factors included are age, gender, BMI, ASA classification, presence of osteoporosis, Dorr classification, revision surgery type and clinical outcome. A number needed to treat (NNT) analysis was conducted assuming that cementing THA prevents EPF. Results 2635 primary THAs were performed. Indications for 70 revisions included 18 EPF in uncemented THA female patients. Periprosthetic fractures without a relevant trauma occurred within six weeks in 16 patients. There was a statistically significant correlation between EPF-risk and age (P = 0.032), female gender (P = 0.001) and ASA classification (P = 0.015). For age ≥75, there was an increase in EPF (P = 0.047). With the assumption that cementing would prevent EPF, the NNT is 48. No statistically significant correlation was found between EPF and BMI, osteoporosis or Dorr classification. Conclusion Female patients aged ≥75 have an increased EPF-risk after uncemented THA and would therefore benefit from treatment with a cemented stem. An ASA score of III-IV is an independent risk factor for EPF after uncemented THA.
Collapse
Affiliation(s)
- S R Hopman
- Department of Orthopedic Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - T S de Windt
- Department of Orthopedic Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - J H J van Erp
- Clinical Orthopedic Research Center - mN, Zeist, Jagersingel 1, 3707, HL, Zeist, the Netherlands.,Department of Orthopedic Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - J E J Bekkers
- Clinical Orthopedic Research Center - mN, Zeist, Jagersingel 1, 3707, HL, Zeist, the Netherlands.,Department of Orthopedic Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - A de Gast
- Clinical Orthopedic Research Center - mN, Zeist, Jagersingel 1, 3707, HL, Zeist, the Netherlands.,Department of Orthopedic Surgery, Diakonessenhuis, Utrecht, the Netherlands
| |
Collapse
|
16
|
Emara AK, Ng M, Krebs VE, Bloomfield M, Molloy RM, Piuzzi NS. Femoral Stem Cementation in Hip Arthroplasty: The Know-How of a "Lost" Art. Curr Rev Musculoskelet Med 2021; 14:47-59. [PMID: 33453016 PMCID: PMC7930165 DOI: 10.1007/s12178-020-09681-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW To describe the (1) indications, (2) preoperative precautions, and (3) stepwise technical details of modern femoral stem cemented fixation. RECENT FINDINGS Femoral stem cementation provides excellent implant longevity with a low periprosthetic fracture rate among patients with compromised bone quality or aberrant anatomy. Unfamiliarity with the details of modern cementation techniques among trainees who may lack frequent exposure to cementing femoral stems may preclude them from offering this viable option to suitable patients in later stages of their careers. As such, maximizing benefit from cemented femoral stem fixation among suitable candidates is contingent upon the meticulous use of modern cementation techniques. In addition to proper patient selection, modern cementation techniques emphasize the use of (1) pulsatile lavage of the femoral canal, (2) utilization of epinephrine-soaked swabs, (3) vacuum cement mixing, (4) retrograde cement introduction, (5) cement pressurization, and (6) the use of stem centralizers. Furthermore, identifying and optimizing the preoperative status of at-risk patients with pre-existing cardiopulmonary compromise, in addition to intraoperative vigilance, are essential for mitigating the risk of developing bone cement implantation syndrome. Further research is required to assess the utility of cemented femoral stem fixation among younger patients.
Collapse
Affiliation(s)
- Ahmed K Emara
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA
| | - Mitchell Ng
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA
| | - Viktor E Krebs
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA
| | | | - Robert M Molloy
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA
| | - Nicolas S Piuzzi
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA.
| |
Collapse
|