Analyses of Prosthesis Stem Failures in Noncemented Modular Hip Revision Prostheses

doi:10.1016/j.arth.2010.05.020

The Journal of Arthroplasty

Volume 26, Issue 4, June 2011, Pages 665.e7-665.e12

https://doi.org/10.1016/j.arth.2010.05.020 Get rights and content

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.

Section snippets

Patients and Methods

Between 2007 and 2010, 4 patients presented in our clinic (university hospital, entire range of services) with previously not identified failures of a noncemented modular revision stem. These cases are analyzed in the following. Clinical data of these patients are listed in Table 1. Primary implantations of the hip prostheses were performed between 1991 and 1998 in different hospitals. In all patients, the primary implantation was performed using a transgluteal approach. Before the stem failure

Case 1

The female patient was emergently presented in our clinic with most severe pain on the left side which had been treated surgically previously several times. X-ray imaging of the hip showed a varus axis deviation of the proximal prosthesis component relative to the stem (Fig. 1A). Prosthesis failure was diagnosed, and stem revision was performed with the MRP system. As the stem was tightly jammed, extensive fenestration of the femur was necessary. Because of hitting out the broken femur

Case 2

The female patient was presented in our clinic because of severe pain in the area of the left hip. The anteroposterior x-ray (Fig. 1C) showed a stem failure. Revision was performed with the noncemented modular revision stem as well. The long fenestration of the femur was fixed with wires (Fig. 1D). The postsurgical course was normal.

Case 3

The male patient was presented in our clinic with pain in the area of the right hip. He had a history of multiple hip surgical procedures in other hospitals. He could not remember any recent trauma. The x-ray image showed a minimal axis deviation between prosthesis neck and stem (Fig. 1E). In a different hospital, this x-ray image had been considered to be normal. Because of the suspected diagnosis of a prosthesis failure, revision surgery was performed which confirmed the stem failure. The

Case 4

The male patient was referred to our hospital after noticing a cracking sound in his left hip 9 years after hip revision surgery using a modular non-cemented revision stem. At the time of the incident the patient performed heavy physical activities (ie, removing snow from the pavement). The patient consequentially fell to the ground and was unable to perform weight-bearing on the left side due to massive pain in the left groin. Anterior-posterior x-rays of the hip (Fig. 1G) revealed a fracture

Results

In all cases, the prosthesis stem failure was diagnosed clinically and radiologically. Special imaging procedures were not necessary. In the 4 presented cases, 3 different noncemented modular revision systems had been implanted. The details are shown in Table 2. All prostheses consisted of a distal tapered titanium stem with a rough surface, a proximal titanium component and a screw fixation between these components.

The failure of all revision stems was located just below the junction between

Failure Analysis by the Manufacturer (case 3)

The anterolateral part of the stem could be identified as fracture starting point (Fig. 2A). In the scanning electron microscopic investigation, the fracture pattern showed typical fatigue fracture characteristics like arrest lines and fatigue lines (Fig. 2B). These are clear indications of dynamic load. After sectioning of the proximal stem component vertical to the fracture plane, there was a grey inhomogeneous layer at the contact surface of the clamping area (Fig. 2C). By means of

Discussion

Modular noncemented revision prostheses represent an important and powerful tool and are obligatory for the treatment of complex cases. To date, aseptic prosthesis loosening is the most common cause (73%) of revision surgery [11]. There is often proximal bone loss due to bone resorption and sometimes additional bone loss due to the surgical removal of the femoral component. Therefore, revision procedures are usually more challenging for the surgeon than primary implantations. Features such as

Acknowledgments

The authors wish to thank Dr. Johanna Schmitt for translating the manuscript into English.

References (21)

Della ValleA.G. et al.
Late fatigue fracture of a modern cemented cobalt chrome stem for total hip arthroplasty: a report of 10 cases
J Arthroplasty
(2005)
JarviK. et al.
Segmental stem fracture of a cemented femoral prosthesis
J Arthroplasty
(2007)
KishidaY. et al.
Stem fracture of the cementless spongy metal Lubeck hip prosthesis
J Arthroplasty
(2002)
ButtaroM.A. et al.
Fatigue fracture of a proximally modular, distally tapered fluted implant with diaphyseal fixation
J Arthroplasty
(2007)
MurphyS.B. et al.
Revision total hip arthroplasty with proximal bone loss
J Arthroplasty
(2004)
BarrackR.L.
Early failure of modern cemented stems
J Arthroplasty
(2000)
VeitC. et al.
BQS-Qualitäts report 2007
BQS
(2008)
The Swedish National Hip Arthroplasty Register annual report 2004
Goteborg
(2005)
RajD. et al.
Stem fracture of a collarless, polished, double-taper cemented femoral prosthesis: a case report
Acta Orthop Belg
(2008)
BuschC.A. et al.
Fractures of distally-fixed femoral stems after revision arthroplasty
J Bone Joint Surg Br
(2005)

There are more references available in the full text version of this article.

Cited by (47)

Gradient nanostructure, enhanced surface integrity and fatigue resistance of Ti-6Al-7Nb alloy processed by surface mechanical attrition treatment
2024, Journal of Materials Science and Technology
Current Ti-based orthopedic implants often suffer from fatigue damage, therefore shortening their service lifespan. To solve this issue, in this study, mechanically polished Ti-6Al-7Nb (P-Ti6Al7Nb) was subjected to surface mechanical attrition treatment (SMAT). Effects of various SMAT process parameters, including ball diameter and treatment duration, on the surface integrity of P-Ti6Al7Nb were investigated, specifically in terms of surface quality, surface nanocrystalline layer, and residual stress. Subsequently, the microstructure, in-depth residual stress and microhardness distributions, surface roughness, and fatigue behavior in simulated body fluids of optimally SMATed Ti-6Al-7Nb (S-Ti6Al7Nb) were examined and compared to those of P-Ti6Al7Nb. Results showed that based on the experimental conditions established in the present research, the optimal parameters were determined to be a 3 mm ball diameter and a 15 min treatment duration, which resulted in excellent surface integrity; S-Ti6Al7Nb showed a 300 μm-thick gradient nanostructured layer comprising the thickest nanocrystalline layer of about 20 μm, a 1000 μm-deep residual compressive stress field with the maximum surface residual compressive stress, and a micro-concave topography but free of any defects or cracks. The microstructural evolution mechanism was also elucidated, revealing that the combination of multidirectional primary and secondary twins’ intersections and twin-dislocation interactions contributed to grain refinement. Compared to P-Ti6Al7Nb, S-Ti6Al7Nb exhibited a 40 % improvement in fatigue strength, owing to synergistic effects of the gradient nanostructured layer, surface work hardening, high amplitude of residual compressive stress, and improved surface integrity. These factors effectively prevented the initiation of fatigue crack at the surface and shifted it to the sublayer, and inhibited the subsequent crack propagation.
Clinical and Radiographic Outcomes of a Monoblock Fluted Titanium-Tapered Stem for Paprosky IIIa, IIIb, and IV Femoral Bone Defects
2023, Journal of Arthroplasty
Modern fluted titanium-tapered stems (FTTS) have been increasingly utilized to achieve primary stability in conversion and revision total hip arthroplasty with major femoral bone loss. This study sought to determine the radiographic and clinical outcomes of a monoblock FTTS in patients who had major femoral bone loss.
A multicenter retrospective observational study of all total hip arthroplasty patients who received a monoblock FTTS who had up to 5-year radiographic follow-up was conducted. Only patients with femoral Paprosky classifications of IIIa, IIIb, and IV were included. Eighty-one monoblock FTTS were examined. Median clinical follow-up was 29 months (range, 18 to 58). Stem subsidence and loosening were assessed on most recent radiographs. All-cause revisions and stem survivals were assessed.
Median subsidence was 1.4 millimeters (mm) (range, 0 to 15.0). Sixteen (23.9%) and 3 (4.5%) stems had subsidence greater than 5 and 10 mm, respectively. All stems not acutely revised appeared stable, without evidence of loosening, at latest follow-up. Ten hips (12.3%) required reoperations. Of these, only 5 (6.2%) stems were removed; 4 due to periprosthetic joint infection and 1 for surgical exposure during acetabular revision. Kaplan–Meier analyses yielded an all-cause stem survivorship of 95.1% at 2-years and 87.1% at 4-years. Stem survivorships excluding septic causes was 98.8% at both 2 and 4 years.
Monoblock FTTS in complex femoral reconstruction cases showed encouraging clinical and radiographic results in patients who had severe femoral bone loss at median 29 months follow-up.
Modular Fluted Tapered Stems in Aseptic Oncologic Revision Total Hip Arthroplasty: A Game Changer?
2020, Journal of Arthroplasty
Modular fluted tapered (MFT) stems are the most frequently used femoral component in revision total hip arthroplasties (THAs). Despite this, no data are available on how they perform in revision THA for oncologic salvage. This is a unique population, often with severe bone loss and prior radiation that extends the limits of uncemented femoral reconstruction. The aims of this study were to evaluate the implant survivorship, radiographic results, and clinical outcomes of MFT stems used for revision oncologic salvage.
We identified 17 patients treated initially with primary THA for an oncologic diagnosis (15 primary oncologic, 2 metastatic disease) who underwent subsequent femoral revision with an MFT stem. Mean age at revision was 66 years and 35% of patients were female. Mean follow-up was 4 years. Before revision, 5 of 17 had undergone local radiation.
Ten-year survivorship free from aseptic loosening was 100%. The survivorship free of any reoperation was 76%. There were no femoral component fractures. Three patients were revised for recurrent instability, and 1 patient underwent irrigation and debridement for an acute infection. At most recent follow-up, no patient had radiographic evidence of progressive femoral component subsidence or failure of osteointegration. The mean Harris Hip Score improved from 29 preoperatively to 76 postoperatively (P < .0001).
In this series of patients with cancer, many of whom had severe bone loss and/or prior local radiation, being treated with revision THA, there were no revisions for femoral component loosening and no cases of implant fracture.
III.
Failure analysis of a modular revision total HIP arthroplasty femoral stem fractured in vivo
2020, Engineering Failure Analysis
An implant fracture is an unusual reason for total hip arthroplasty (THA) revision; however, it may cause serious clinical complications. The stress in femoral stems may increase considerably with the loss of bone support around the implant, leading to implant failure. This paper investigates the main reasons for the in vivo fracture of a Ti6Al4V revision femoral ZMR stem. Various methods were used: examination of the patient’s by radiographies; optical emission spectrometry; and Scanning Electron Microscopy (SEM). The titanium (Ti) alloy was also characterized through optical microscopy and a Vickers hardness test was carried out. A finite element analysis (FEA) was conducted to evaluate the stress distribution occurring in the femoral stem revision under loading.
The chemical composition and microstructure of the prosthesis did not reveal any non-conformity. The SEM analysis revealed fretting damage near the crack initiation site and the fractured surfaces exhibited characteristic ratchet marks, poorly formed striations and a small final fracture area. The FEA showed a stress concentration located at the proximal–distal taper junction, with a smaller diameter, coinciding with the crack initiation site.
The conclusion was that fatigue failure was due to a lack of bone sustainability that increased the stress, associated with design characteristics that caused a localized concentration of stress, and these were potentialized by a fretting mechanism, leading to the failure.
Is There a Benefit to Modularity for Femoral Revisions When Using a Splined, Tapered Titanium Stem?
2020, Journal of Arthroplasty
Proposed benefits of modularity for femoral revisions in total hip arthroplasty (THA) include more precise biomechanical restoration and improved stability, but this has not been proven with use of a splined, tapered design. This study’s purpose is to compare (1) complication rates, (2) functional outcomes, and (3) radiographic measures of subsidence, offset, and leg length discrepancy with the use of modular vs monoblock splined, tapered titanium stems in revision THA.
We retrospectively reviewed 145 femoral revisions with minimum 2-year follow-up (mean, 5.12 years; range, 2-17.3 years). Patients receiving a modular (67) or monoblock (78) splined, tapered titanium stem for femoral revision were included.
There were no statistically significant differences in rates of reoperation (22.3% vs 17.9%; P = .66), intraoperative fracture (9.0% vs 3.8%; P = .30), postoperative fracture (3.0% vs 1.3%; P = .47), dislocation (11.9% vs 5.1%; P = .23), or aseptic loosening (4.5% vs 6.4%; P = .73) between the modular and monoblock cohorts, respectively. There were similar results regarding subsidence >5 mm (10.4% vs 12.8%; P = .22), LLD >1 cm (35.8% vs 38.5%; P = .74), restoration of hip offset (−5.88 ± 10.1 mm vs −5.07 ± 12.1 mm; P = .67), and Harris Hip Score (70.7 ± 17.9 vs 73.9 ± 19.7; P = .36) between groups. Multivariate regression showed no differences in complications (P = .44) or reoperations (P = .20) between groups.
Modular and monoblock splined, tapered titanium stems demonstrated comparable complication rates, functional outcomes, and radiographic parameters for femoral revisions. However, a limited number of patients with grade IIIB or IV femoral bone loss received a monoblock stem. Future investigations are required to determine whether modularity is beneficial for more complex femoral defects.
Early outcomes after revision total hip arthroplasty with a modern modular femoral revision stem in 65 consecutive cases
2019, Arthroplasty Today
We evaluated the early outcomes, including all-cause revisions, aseptic revisions, and reoperations after revision total hip arthroplasty (THA) using a single modern modular femoral stem design.
A retrospective cohort study on a consecutive series of 62 patients (65 hips) who underwent revision THA with a modern modular femoral stem system, between January 2011 and October 2015, at a single academic medical center was performed. A cumulative incidence competing risk model was used to evaluate the cumulative incidence of failure with death as the competing risk.
The cumulative incidence rate of all-cause revision THA was 14.5% (95% confidence interval [CI], 6%–24%) at 2 years when accounting for the competing risk of death. The rate of aseptic revisions was 6.8% (95% CI, 0.1%–13%), and the rate of all-cause reoperations was 21.6% (95% CI, 11%–31%). Ten THA cases (15%) underwent re-revision THA for any reason: five for infection and five for aseptic failures. The mean time to re-revision was 1 year (range, 0.04–5.34). Patients with a preoperative Mallory classification of 3 or more were at greater risk for reoperation (sub-hazard rate, 3.84; 95% CI, 1.54–9.53; P = .004).
Although the high incidence of reoperation illustrates the complexity of the revision THA population, particularly related to infection and joint instability, the relatively low rate of aseptic failures, minimal radiographic subsidence, and the lack of modular junctional failures suggest that the use of this modular revision THA system may provide adequate fixation and could be considered as a viable treatment option in the setting of revision THA.

View all citing articles on Scopus

: No benefits or funds were received in support of the study.

View full text

Case ReportAnalyses of Prosthesis Stem Failures in Noncemented Modular Hip Revision Prostheses

Abstract

Section snippets

Patients and Methods

Case 1

Case 2

Case 3

Case 4

Results

Failure Analysis by the Manufacturer (case 3)

Discussion

Acknowledgments

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

BQS-Qualitäts report 2007

BQS

The Swedish National Hip Arthroplasty Register annual report 2004

Goteborg

Stem fracture of a collarless, polished, double-taper cemented femoral prosthesis: a case report

Acta Orthop Belg

Fractures of distally-fixed femoral stems after revision arthroplasty

J Bone Joint Surg Br

Case Report
Analyses of Prosthesis Stem Failures in Noncemented Modular Hip Revision Prostheses