Does Introduction of a Taper-Slip Polished Cemented Stem Reduce Early Periprosthetic Fracture Risk with Anterior Approach Total Hip Arthroplasty?

doi:10.21203/rs.3.rs-5204834/v1

Background

Anterior approach total hip replacement (AA-THA) is associated with higher periprosthetic fracture (PFF) risk. Cemented femoral fixation may reduce this risk. This study aims to 1) determine if using a cemented polished taper-slip (PTS) stem reduces PFF risk, 2) describe perioperative complications, and 3) identify factors associated with outcome.

Methods

This was a retrospective, case-matched cohort study from an academic center. The first 122 hybrid AA-THAs with a minimum 12-month follow-up were reviewed. These were matched (2:1) for age, sex, BMI, femoral and pelvic morphology with 244 AA-THAs using an uncemented, short, stem. Outcomes measured include PPF (Vancouver classification) rate, reoperation rate, complications, cement quality, and radiologic measurements.

Results

Nineteen PFFs (5.1%) occurred at a mean 14.5±23 days following surgery. There was no difference in PPF rate between groups (CS: 7/122, 5.7%, 5/7 Type-A and 2/7 Type-B₂; US: 12/244, 4.9%, 7/12 Type-A, 4/12 Type-B₂ and 1/12 Type-C; p=0.847). There was no difference in PPF risk between short (≤125 mm) and normal length (150 mm) stems (p=0.676). More uncemented stems subsided (CS: 1/122, 0.8%; US: 27/244, 11.1%; p<0.001). Suboptimum cementation was noted in 16 (13%) hips; two fractured and one subsided (risk-ratio [RR]: 3.9; p=0.035). A narrow ischial width and high ilio-ischial ratio were the only morphological parameters associated with risk of PPF and subsidence.

Conclusion

Hybrid AA-THA did not reduce PFF risk. Suboptimal cementation was associated with increased risk of subsidence or fracture. Current instruments do not accommodate the limited working window and steeper femoral angle during AA-THA.

Anterior approach

periprosthetic femur fracture

taper-slip stem

cemented stem

Total hip arthroplasty (THA) remains one of the most successful procedures in orthopaedic surgery (1), and outcomes continue to improve with newer implant designs and refinements of surgical approaches. The anterior approach total hip replacement (AA-THA) has grown in popularity due to perceived benefits such as faster postoperative recovery and reduced dislocation-risk (2–7). However, femoral exposure and preparation can be challenging and lead to suboptimal stem sizing or malposition. This may explain, in part, why the AA-THA has constantly been associated with a higher risk of periprosthetic fracture (PFF) of the proximal femur (8,9). To facilitate femoral preparation and introduction of the femoral prosthesis into the canal, shorter uncemented femoral stems (US) were designed for easier broaching and stem insertion. However, there have been reports on increase femoral fractures with shorter single-wedge prosthesis design (10,11).

Compared to cementless stems, cemented femoral stems (CS) are thought to be associated with lower rate of PFF (12,13). Yet, cemented stems accounted for only 4.55% of primary THAs in the United States in 2022, as per the American Joint Replacement Registry (14). Together, the reported advantages the anterior approach and cemented fixation may reduce the risk of PFF while improving perioperative outcomes. Therefore, there is growing interest to determine the feasibility and safety of performing an AA-THA using contemporary cemented stems and technique.

Several studies have recently reported good clinical results – adequate cement mantle and stem alignment – with cemented femoral stems through an anterior approach (15–17). However, there is currently a lack of evidence comparing differences in PFF rate and perioperative outcomes between cemented and uncemented femoral stems during elective AA-THA at an institutional level.

This study aims to 1) determine if using a cemented polished taper-slip (PTS) stem during primary AA-THA reduces PFF risk, 2) describe perioperative complications leading to revision surgery, and 3) identify factors associated with outcome.

Study design

This was a retrospective, multi-surgeon, case-matched cohort study from a single academic tertiary referral unit between January 2016 and December 2022. The study was approved by the institutional review board.

An a priori sample size calculation was performed. Based on a difference in complication rate of 4% between hybrid and uncemented THAs (18) and an enrollment ratio 1:2, a minimum of 121 cases in the cemented AA-THA group and 242 cases in the uncemented AA-THA group was needed to achieve sufficient power (1-b= 0.80, α = 0.05).

Study Population

In 2018, hybrid AA-THA using a cemented femoral component was introduced in our unit’s elective arthroplasty practice (15). This was aimed to reduce our institutional PFF rate with the AA-THA which was previously reported to be between 3.4 – 4.35% (19,20). For this study, the first 122 hybrid AA-THAs with a cemented PTS femoral stem with a minimum of 12-month follow-up were included for review. These cases were performed by one of three fellowship-trained arthroplasty surgeons (PEB, SG, GG) well experienced with AA-THA. All cases were obtained from a prospectively maintained arthroplasty database at our institution. Inclusion criteria included consecutive adult patients (≥18 years) who underwent primary, elective, AA-THA with a cemented stem for an indication of osteoarthritis (OA). We excluded all patients with a diagnosis other than OA, and those who received a hip hemiarthroplasty, hip resurfacing arthroplasty, or revision THA performed through an anterior approach. Our initial institutional experience of the first 58 cemented femoral components, regardless of arthroplasty-type, has been previously described (15).

To compare outcomes between hybrid AA-THAs and AA-THA performed with an uncemented stem, we retrospectively retrieved prospectively collected data from our institutional arthroplasty database of patients who underwent elective, primary, AA-THA with a short cementless, titanium, flat, tapered stem (Taperloc Microplasty Complete Hip System, Zimmer-Biomet, Warsaw, Indiana, USA), between January 1, 2016 and October 31, 2018. Only cases for an indication of OA and performed by the same surgeons were included (n = 901). To minimize variability and balance cohorts with respect to baseline characteristics, patients who underwent AA-THA with a cemented stem were matched for patient factors known to influence PPF risk (age, sex, body mass index (BMI), Dorr classification and femoral and pelvic morphological characteristics) in a 1:2 fashion with 244 uncemented AA-THAs (Table 1).

Surgical Procedure

All patients received preoperative antibiotics and 1 gram of intravenous tranexamic acid (TXA) prior to skin incision. Decision to use a general or spinal anesthetic reflected the anesthesiologist’s and patient’s decision.

All surgeries were performed either using a standard operating table or an orthopaedic positioning table (Hana Orthopedic Surgery Table, Mizuho OSI, Union City, CA or RotexTable, Condor, MedTec). A cementless acetabular cup was used in all patients (G7 Acetabular Shell; Zimmer Biomet, Warsaw, IN) with a highly cross-linked polyethylene liner. Three different PTS femoral stems were used: Exeter Femoral Hip Stem (Stryker) n=64 (53%); Sirius Cemented Femoral Hip Stem (Zimmer Biomet) n= 40 (33%); C-Stem AMT (Depuy Synthes) n=18 (14%) - all collarless highly polished double-taper design. The choice of femoral stem depended on inventory of femoral stem at the site where surgery took place. The Sirius stem stopped being available in North America in 2020. All stems were cemented in standard fashion using 3^rd generation cementing technique. Antibiotic cement was used in all cases (Palacos+G, Heraeus Medical, Germany). The short Exeter stem (125mm in length 37.5 and 44mm offset stems) were used in 33 cases.

A standardized postoperative protocol was followed in all patients, allowing immediate full weight bearing. All patients were assessed by physiotherapy before hospital discharge. Routine, 30-day deep venous thrombosis (DVT) prophylaxis was used in all cases. Patients were reviewed clinically at 2 weeks, 6 weeks, 6 months, 12 months, and annually thereafter.

Outcome Measurements

Outcome measures included PPF rate, revision arthroplasty rate, and intraoperative and postoperative complications. The Dindo-Clavien classification system was used to grade complications (21). Grade 1 complications needed no treatment. Grade 2 complications required pharmacologic treatment, including superficial wound infections treated with antibiotics. Grade 3 complications resulted in reoperation, including PPF, periprosthetic joint infection (PJI), subsidence, instability, and aseptic joint loosening. Grade 4 complications were potentially life-threatening complications, and grade 5 complications resulted in death.

Radiographic assessments were performed on antero-posterior (AP) pelvic radiographs. Post-operative radiographs at 6 weeks served to evaluate cementation quality using the Barrack and Harris grading system (22) and stem coronal alignment (neutral: varus/valgus 0±3º; varus 3-5º; varus >5º) (Figure 1). Similarly, stem subsidence assessment was done based on radiographs obtained at the 1-year follow-up, or last available radiograph in patients who fractured earlier. Injury radiographs of all patients with a PFF were retrieved and reviewed by a fellowship-trained arthroplasty surgeon (JBM). Fractures were categorized using the Vancouver classification system (23). In addition, radiographic measurements of proximal femur and pelvic morphological parameters were performed using pre-operative supine radiographs (20). All radiographs included a 25 mm marker to avoid magnification error. Analysis was performed by 2 fellowship-trained arthroplasty surgeons (JBM and GG) with previously described excellent intra- and inter-observer coefficients (0.720-0.990 and 0.751-0.970, respectively) (20) using the criteria defined by Landis and Koch (24). Proximal femoral geometry was measured using canal-ﬂare index (CFI) (25), canal-calcar ratio (CCR) (26), canal-bone ratio (CBR) (27), and the morphological cortical index (MCI) (28). Pelvic parameters measured include the ilium-ischial ratio (IIR) (29) and the distance from the anterior superior iliac spine to the tip of the greater trochanter (ASIS-GT). These measurements can be calculated on the pelvic AP radiograph (Figure 2).

Data Analyses

Descriptive statistics are presented as means and standard deviations. Categorical variables are presented as absolute numbers and percentages. Non-parametric tests were used for data analysis. The Mann Whitney U test was used to compare continuous data between groups. Cross-tabulated data was compared using the chi-squared test, or Fisher’s Exact test where any expected cell count was <5, and odds ratios (with 95% confidence intervals (CI)) were calculated. Correlations were tested using Spearman’s rho. Factors that were independent predictors of fracture were determined using univariate and multivariate analysis. Variables that were correlated with one another were removed from the multivariate analysis. All statistical analysis was performed using SPSS Statistical Software (version 27.0, SPSS Inc., Armonk, New York). Statistical significance was set at p<0.05.

There were 19 PFFs (5.2%) that occurred at a mean of 14.5±23 days following index surgery. There was no difference in PPF rate between groups (CS: 7/122 [5.7%], 5/7 Type-A and 2/7 Type-B₂; US: 12/244 [4.9%], 7/12 Type-A, 4/12 Type-B₂ and 1/12 Type-C; p=0.847). There was no difference in fracture risk between shorter (≤125 mm) cemented stems (6.3%) and standard length (150 mm) cemented stems (3.1%) (p = 0.676). There was no difference in PPF rate between those AA-THA performed using a standard operating table (p=0.320).

At a minimum 12-month follow-up, 14 cases required revision surgery (3.8%), with no differences between groups (CS: 6/122 [4.9%]; US: 8/244 [3.3%]; p=0.232) (Table 2). The two most common reasons for requiring revision surgery were PPF (6/14, 42.9%) and periprosthetic joint infection (5/14, 35.7%). Five patients (1.3%) experienced a dislocation, but only one patient in the cemented AA-THA group required revision surgery. Significantly more uncemented stems subsided (CS: 1/122, 0.8%; US: 27/244, 11.1%; p<0.001) with one patient in the uncemented AA-THA group required revision surgery.

A narrow ischial width and high IIR were the only pelvic and femoral morphological parameters associated with risk of PPF and/or subsidence (Table 3). Suboptimum cementation (Barrack grade C or D) was appreciated in 16 hips (13%), two of which fractured (both Vancouver B₂) requiring revision surgery and one subsided (Risk-ratio [RR]: 3.9; p=0.035). Hips with suboptimum cementation were found to have narrower ASIS-GT distance (89.3±18 vs. 100.3±17 mm; p=0.013), smaller CFI (3.1±0.5 vs. 3.5±0.6; p=0.012) and MCI (2.4±0.3 vs 2.7±0.3; p=0.02), and larger CCR (0.53±0.08 vs. 0.47±0.07; p=0.007) and CBR (0.48±0.06 vs 0.45±0.07; p=0.03) (Table 3).

Minimizing complications following THA is a cornerstone for successful outcome. Peri-prosthetic fracture following THA is a recognized complication with higher rates amongst uncemented THAs, especially in elderly patients and with the AA-THA. To minimize PFF, in our institution we introduced the selective use of hybrid AA-THA with a cemented PTS stem. This case-control study concurs with previous reports that AA-THA performed with a cemented PTS stem is safe. However, contrary to our expectation, the use of cemented PTS stems during the introductory phase was not associated with reduced PFF or revision/complication rates compared to a collarless short stem which has been our institutional stem of choice for years. This is important information during decision making when changing stem designs/philosophy. Most fractures were Vancouver A_GTand most likely occurred during elevation of the femur for appropriate preparation. Lack of specialised instruments for the AA-THA to insert a longer stem and the cement restrictor likely contributed. A significant proportion of cases were associated with sub-optimal Barrack grades of cementation, which thereafter translated to increased risk of subsidence or fracture (RR:3.9). While individual bony morphology likely contributes to this by impeding adequate exposure for cementation, perhaps use of smaller, more flexible nozzles paired with low viscosity cement could improve cement interdigitation. The results described should raise awareness that a switch in practice might not be associated with the desired outcome and constant practice audit is prudent. Further longitudinal and higher evidence-level studies are necessary to assess whether greater institutional experience with a given technique improves outcome.

The anterior approach is a commonly utilized surgical approach for primary THA (25). While advocates of this surgical approach claim many benefits, including faster rehabilitation, more reliable cup orientation, and lower dislocation-risk (26–29), there is a higher risk of PFF (8,9,30). One of the challenges with the AA-THA is the safe delivery of the femur to allow femoral broaching. Inadequate exposure can result in canal perforation, suboptimal stem sizing, malposition of the stem, or even fracture (30). To mitigate this, shorter uncemented stems have been designed to allow for broach-only femoral preparation and easier introduction of the prosthesis at a steeper angle into the femoral canal (31,32). However, these stems may not be appropriate for allcomers (20). The use of a cemented stem in patients at increased PPF-risk due to bone physiology or hip morphology is an attractive option. Several studies have reported on the safe introduction of AA-THA with a cemented stem (15–17). These observations and reports led to the selective use of cemented stems in our practice.

Contrary to previous reports on the use of cemented stems with the AA-THA (16,18,33–35) in this case-control matched study we did not find a reduced PFF rate compared to a well-established, uncemented short stem (36). This is likely to be the case due to numerous reasons. Firstly, most of the fractures encountered where Vancouver A_GT that were detected in the immediate post-THA radiograph. These most likely occurred during femoral elevation. Greater femoral elevation and mobilization is necessary for A) safe introduction of a longer stem; B) working with straight instruments (e.g., when inserting a contemporary cement restrictor or specific broaches); and C) smaller pelvic-femoral window (i.e. IIR and ASIS-GT distance). Secondly, two of the fractures (Vancouver B₂) occurred after a trauma in the post-operative period. The association of PTS stems with Vancouver B₂ fractures has been well-described in the literature due to the log-splitting characteristics of the injury (37,38). Cemented PTS stems have been associated with greater PFF-risk compared to composite-beam type stems according to registry data (38–40). Furthermore, most previous reports with the AA-THA have been with non-PTS stems (18,35). Additionally, in this study due to easier insertion during AA-THA, a significant proportion of cases used shorter (≤125 mm) PTS stems (33/122; 27%). Both fractures occurred around short cemented stems. In vitro work has demonstrated that short PTS stems require smaller loads to failure and are thus more prone to PFF (41–43), when greater than physiological loads are applied (such as trauma) (42). This observation has further been reported by registry data (44). It has now been our preference to minimize use of short PTS as much as possible. Thirdly, an association between sub-optimum cementation/stem position and fracture was identified. As this cohort includes the surgical and institutional learning curves with the use of cement and the AA-THA, it is anticipated that this would improve with experience. It does highlight however, that upon change of practice to cemented stems, no immediate effect is guaranteed as other factors might be at play. Furthermore, it highlights that a well-performed uncemented stem, might perform as well as a poorly performed cemented stem. Comparatively, using data from the Australian National Joint Replacement Registry, Hoskins recently compared cumulative percent revision between 10,742 AA-THAs and 49,997 THAs performed through the posterior approach. Patients were matched for age, sex, ASA score, BMI, and femoral head size. The authors reported no difference in rate of revision surgery for fracture between groups (HR 1.01 [95% CI, 0.71–1.43]), p=0.975) (45).

The comprehensive radiographic analysis performed identified that a significant proportion of cases subsided (8.7%). Only 1 patient in the uncemented AA-THA group that exhibited subsidence required revision surgery. However, given that subsidence could lead to fracture, we grouped the two when testing for morphological factors that could be associated. The factor that showed the greatest association was the IIR. A high ratio implies a narrow working window, which has been previously shown to be associated with complications with the AA-THA. We thus recommend caution as part of preoperative templating. Previous studies have recommended use of cemented stem with the AA-THA in the presence of a high IIR (20), however the results of this study with PTS do not fully support this at present. Further study is necessary to assess whether composite beam or uncemented collared stems are a better implant choice for such patients (46,47).

This study was not without potential limitations. Firstly, this study is a retrospective review of prospectively collected data and suffers from all associated biases with such design, including selection bias. No standardized criteria for choosing which patients received a cemented or uncemented AA-THA were followed; stem use was thus a reflection of surgeon preference to manage risk and maximize patient safety. However, given the low incidence of PFF following elective AA-THA, registry- and observational studies serve as the best evidence currently available. Case matching was performed as closely as possible using parameters described in the literature – however, it is possible that parameters not easily captured with retrospective designs remain at play. Secondly, three different PTS stems were used within the cemented group, differentiating from the US group in which only one stem design was used. All three stems were of TPS design; however, they have subtle design differences, which are thought to be associated with the differences in PPF incidence seen with different stems and lengths (39). Unfortunately, our study is underpowered to compare the rate of PFF between different CS.

In conclusion, our findings show that cemented PTS stem through AA-THA did not reduce the risk of PFF or revision surgery compared to cementless fixation within 12-months following index surgery. The most encountered fracture in patients with a cemented stem were fractures of the GT. We believe that current instrumentation that is not designed to accommodate the limited working window and steeper femoral angle is perhaps in par accountable for these fractures. Future research and development are needed to develop equipment to facilitate cementing femoral stems through the anterior approach.

Funding statement:

No funding was received for this study

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Mabrouk A, Feathers JR, Mahmood A, West R, Pandit H, Lamb JN. Systematic Review and Meta-Analysis of Studies Comparing the Rate of Post-operative Periprosthetic Fracture Following Hip Arthroplasty With a Polished Taper Slip versus Composite Beam Stem. J Arthroplasty. 2024 Jan;39(1):269-275. doi: 10.1016/j.arth.2023.06.014.
Freitag T, Kutzner KP, Bieger R, Reichel H, Ignatius A, Dürselen L. Biomechanics of a cemented short stem: a comparative in vitro study regarding primary stability and maximum fracture load. Arch Orthop Trauma Surg. 2021 Oct;141(10):1797-1806. doi: 10.1007/s00402-021-03843-x.
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Table 1. Patient demographics and matched variables.

Patient characteristics		Cohort (n=366)	Cemented (n=122)	Uncemented (n=244)	p value
Age (years)		76.1±7.1	75.6±9.2	76.3±5.8	0.57
Sex (%)	Women	235 (64.2)	81(66.4%)	154 (63.1%)	0.53
Sex (%)	Men	131 (35.8)	41 (33.6%)	90 (36.9%)	0.53
Body Mass Index (kg/m²)		26.7±4,9	27.1±5.1	26.4±4.8	0.24
DORR Classification (%)	A	81 (22.1)	22 (18)	59 (24.2)	0.21
	B	256 (69.9)	86 (70.5)	170 (69.7)
	C	29 (7.9)	14 (11.5)	15 (6.1)
Acetabular Cup Type	G7	366	122	244
Femoral Stem Type	Exeter	64	64	0
	Sirius	40	40	0
	C-stem	18	18	0
	Taperloc Microplasty	244	0	244
Femoral Head Size (%)	28mm	4 (0.1)	2 (1.6)	2 (0.08)	<0.001*
	32mm	142 (38.8)	27 (22.1)	115 (47.1)
	36mm	215 (58.7)	90 (73.7)	125 (51.2)
	Dual mobility	5 (0.13)	3 (0.12)	2 (0.08)
Femoral Morphological Parameters	CFI	3.787±2.59	3.514±0.62	3.959±3.28	0.06
	CCR	0.482±0.21	0.482±0.07	0.464±0.06	0.02*
	CBR	0.449±0.06	0.458±0.07	0.445±0.06	0.29
	MCI	2.727±0.38	2.681±0.38	2.758±0.38	0.08
Pelvic Morphometric Parameters	Ilium Width (mm)	302.8±27.6	302.2±24.6	303.3±29.4	0.69
	Ischial width (mm)	104.3±15.1	104.1±15.1	104.4±15.2	0.55
	Ilio Ischial Ratio (IIR)	2.954±0.44	2.951±0.41	2.958±0.47	0.99
	ASIS-GT (mm)	98.7±18.1	98.8±17.9	98.7±18.3	0.86

CFI: Canal flare index; CCR: Canal calcar ratio; CBR: Canal bone ratio; MCI: Morphological cortical index. ASIS-GT: Distance from the anterior superior iliac spine to the tip of the greater trochanter.

Table 2. Complications presented in Cemented and Uncemented femoral stems

Complication			Cohort n=366 (%)	Cemented n=122 (%)	Uncemented n=244 (%)	P value
Periprosthetic Fracture			19 (5.1)	7 (5.7)	12 (4.9)	0.847
Vancouver Classification	A		12	5	7	0.873
	B₂		6	2	4
	C		1	-	1
Dislocation			5 (1.3)	4 (3.2)	1 (0.4)	0.122
Subsidence			32 (8.7)	1 (0.8)	31 (12.7)	0.001*
Revision Surgery			14 (3.8)	6 (4.9)	8 (3.3)	0.232
	Periprosthetic fracture		6	2	4
		Exeter	5	5
		C-stem	1	1
		Sirius	0	0
	Periprosthetic joint infection		5	2	3
	Subsidence		1	0	1
	Instability		1	1	0
	Acetabular aseptic loosening		1	1	0

* Statistical difference (p<0.05).

Table 3. Morphometric pelvis and femoral parameters associated with quality of cementation, PPF and subsidence

	Cementation Quality			Fracture/Subsidence
	Barrack 1&2 (n=106)	Barrack 3&4 (n=16)	P value	No (n=318)	Yes (n=48)	P value
CFI	3.576±0.61	3.15±0.51	0.012*	3.587±0.58	3.537±0.49	0.638
CCR	0.474±0.07	0.534±0.08	0.007*	0.47±0.06	0.475±0.07	0.715
CBR	0.453±0.07	0.489±0.06	0.032*	0.448±0.06	0.463±0.06	0.155
MCI	2.715±0.37	2.468±0.37	0.02*	2.73±0.38	2.718±0.4	0.721
Ilium Width (mm)	303±24.5	296.5±24	0.283	302.6±28.4	304.474±22.5	0.694
Ischial width	103.9±15	105.9±15.9	0.545	105.1±15.1	99.1±14.3	0.01*
IIR	2.963±0.4	2.85±0.4	0.158	2.927±0.4	3.131±0.4	0.008*
ASIS-GT (mm)	100.3±17.4	89.3±18.1	0.013*	99.1±18.4	96.2±16.1	0.249

CFI: Canal Flare index; CCR: Canal Calcar ratio; CBR: Canal Bone ratio; MCI: Morphological Cortical index; IIR: Ilio Ischial ratio; ASIS- GT: Distance from superior iliac spine to the tip of the greater trochanter. * Statistical difference (p<0.05)

No competing interests reported.

Does Introduction of a Taper-Slip Polished Cemented Stem Reduce Early Periprosthetic Fracture Risk with Anterior Approach Total Hip Arthroplasty?

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