Elsevier

The Journal of Arthroplasty

Volume 15, Issue 8, December 2000, Pages 1036-1050
The Journal of Arthroplasty

Review Articles
Early failure of modern cemented stems*,**

https://doi.org/10.1054/arth.2000.16498Get rights and content

Abstract

In the late 1970s, improved cement technique was introduced in an attempt to address the problem of early cemented stem loosening. Subsequently, numerous centers reported stem survival rates of >95% beyond 10 years. Long-term cemented stem fixation was believed widely to be consistently obtainable in most patients. Despite the widespread clinical success of these early cemented stems, numerous changes were introduced in stem design and cement technique. In more recent years, a surprising number of series of early failures of cemented stems have been reported. Some designs consistently have had a high early failure rate. Others have failed infrequently, but the failures have occurred early and with extensive osteolysis. Numerous causes have been proposed, including poor cement technique, undersized broaches, increased stem offset, decreased stem length, rough surface finish, and circular stem cross-section. Failures often are multifactorial and defy a simple explanation based on a single parameter. Results of cemented stems are more variable than previously appreciated. There are nuances of cemented stem design, cement technique, and patient selection that can lead to early failure and that are not understood completely at present. Given the availability of many cemented designs with proven records of clinical success, new design features should be introduced prudently with extensive premarket testing, limited clinical release, and careful postmarket surveillance.

Section snippets

Surgical technique

Among the most dramatic reports of early stem failures is that of the Capital THA (3-M Healthcare Limited, Loughborough, UK). This stem was described as being “similar to that of the Charnley prosthesis.” [23] It was touted as a low-cost option in place of the Charnley stem and was fabricated of titanium alloy and had a titanium nitrite-coated modular head as an option [23]. Definite loosening was present in 16% with an additional 8% possibly loose at follow-up of 26 months. Approximately 5,000

Stem design

Many changes have occurred in the design details of cemented stems, many of which have been associated directly or indirectly with early failure. A series of failures that was relatively rare but dramatic and was associated with a design detail was that of 10 fractured forged cobalt-chrome stems reported by Woolson et al in 1997. These 10 fractured stems represented 2% of the implants in that series [45]. Fracture of a forged cobalt-chrome cemented stem previously had been considered to be rare

Patient selection

There is evidence that certain cemented stems of more recent design are more prone to failure in certain types of patients. In the series of early failures with the Centralign stem reported by Santore [51], the average patient age was 49 years. When Sporer et al [52] examined the precoated Iowa Hip in patients <50 years old, the revision rate was 18% at 5 to 10 years compared with only 3% for the group of Iowa hips overall. The precoated Iowa stems were compared with the same stem with a

Variability of results

The most striking aspect of numerous clinical series of modern cemented stems is the extreme variability in the reported rates of revision and osteolysis. The prime example is probably the Precoat stem (Zimmer, Inc, Warsaw, IN). Dowd et al [27], Woolson et al [43], and Ong et al [56] reported failure rates of 5% to 14% at 6 years, whereas an equal number of series reported failure rates of <1% at longer-term follow-up of 8 to 10 years (Table 3) 42, 58, 59.

. Variable Results With Cemented Stems at

Discussion

Although the percentage of cementless femoral stems implanted has increased, cemented femoral stems still constitute most components implanted, particularly in the United States [64]. A resurgence in popularity of cemented stems is due to many factors, including perceived lower cost; emergence of problems with early-generation cementless devices; and reports of excellent long-term results that emerged with early-generation designs, such as the Charnley, Exeter, HD2, and Spectron. Excellent

References (68)

  • S Tankersley et al.

    Comparison of first and second generation cementless prostheses

    J Arthroplasty

    (1996)
  • RN Stauffer

    Ten-year follow-up study of total hip replacement

    J Bone Joint Surg Am

    (1982)
  • CJ Sutherland et al.

    A ten-year follow-up of one hundred consecutive Muller curved-stem total hip replacement arthroplasties

    J Bone Joint Surg Am

    (1982)
  • HP Chandler et al.

    Total hip replacement in patients younger than thirty years old: a five year follow-up study

    J Bone Joint Surg Am

    (1981)
  • LC Jones et al.

    Cement disease

    Clin Orthop

    (1987)
  • RL Barrack et al.

    Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty: a 12-year radiographic review

    J Bone Joint Surg Br

    (1992)
  • WH Harris et al.

    Loosening of the femoral component after use of the medullary-plug cementing technique

    J Bone Joint Surg Am

    (1986)
  • WF Mulroy et al.

    Total hip arthroplasty with use of so-called second-generation cementing techniques

    J Bone Joint Surg Am

    (1995)
  • GM Russoti et al.

    Cemented total hip arthroplasty with contemporary techniques: A five-year minimum follow-up study

    Clin Orthop

    (1988)
  • WF Mulroy et al.

    Revision total hip arthroplasty with use of so-called second-generation cementing techniques for aseptic loosening of the femoral component

    J Bone Joint Surg Am

    (1996)
  • KR Schulte et al.

    The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up

    J Bone Joint Surg Am

    (1993)
  • BM Wroblewski et al.

    Stem fixation in the Charnley low-friction arthroplasty in young patients using an intramedullary bone block

    J Bone Joint Surg Br

    (1998)
  • JL Fowler et al.

    Experience with the Exeter total hip replacement since 1970

    Orthop Clin North Am

    (1988)
  • H Malchau et al.

    Prognosis of total hip replacement, revision and re-revision rate in THR: a revision risk study of 148,359 primary operations

    Scientific exhibit

    (March 1998)
  • SW Smith et al.

    Total hip arthroplasty with use of second-generation cementing techniques

    J Bone Joint Surg Am

    (1998)
  • CA Engh et al.

    Long-term results of use of the anatomic medullary locking prosthesis in total hip arthroplasty

    J Bone Joint Surg Am

    (1997)
  • RC Gardiner et al.

    Failure of the cement-bone interface: a consequence of strengthening the cement-prosthesis interface?

    J Bone Joint Surg Br

    (1994)
  • CG Mohler et al.

    Early loosening of the femoral component at the cement-prosthesis interface after total hip replacement

    J Bone Joint Surg Am

    (1995)
  • CR Dreghorn et al.

    Revision arthroplasty: a high price to pay

    BMJ

    (1989)
  • SN Massoud et al.

    Early femoral loosening in one design of cemented hip replacement

    J Bone Joint Surg Br

    (1997)
  • SK Muirhead-Allwood

    Lessons of a hip failure: if we want improved prostheses we must regulate their use

    BMJ

    (1998)
  • RS Nizard et al.

    Ten year survivorship of cemented ceramic-ceramic total hip prostheses

    Clin Orthop

    (1992)
  • JE Dowd et al.

    Failure of total hip arthroplasty with a precoated femoral prosthesis: 4 to 11 year results

    Clin Orthop

    (1998)
  • K Kawate et al.

    Importance of a thin cement mantle: autopsy study of eight hips

    Clin Orthop

    (1998)
  • Cited by (0)

    *

    Funds were received from Smith & Nephew, Inc, in support of the research material described in this article.

    **

    Reprint requests: Robert L. Barrack, MD, Tulane University School of Medicine, Department of Orthopaedic Surgery, 1430 Tulane Avenue, SL 32, New Orleans, LA 70112.

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