The short-term outcomes of cementless collared triple-tapered stem for primary total hip arthroplasty in patients ≥70-years old

Whisper Grayson; Carlo Eikani; Nicholas M. Brown; Daniel Schmitt

doi:10.1016/j.jor.2024.10.055

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63 (); 77-80

doi:

10.1016/j.jor.2024.10.055

The short-term outcomes of cementless collared triple-tapered stem for primary total hip arthroplasty in patients ≥70-years old

Whisper Grayson , Carlo Eikani, Nicholas M. Brown, Daniel Schmitt

Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA

⁎Corresponding author: Whisper Grayson. whisper.grayson@luhs.org

Received: 2024-10-23, Accepted: 2024-10-31, Published: 2024-11-1

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Periprosthetic fractures and mechanical failure following total hip arthroplasty (THA) are not uncommon occurrences in elderly patients, especially with the use of cementless implants. The utilization of collared, triple-tapered femoral stems has demonstrated good clinical outcomes and results comparable to other femoral stems. There remains a paucity of literature on the use of these stems in older patients. In this study, we evaluated post-operative outcomes following primary THA in patients ≥70-years old using a collared, triple-tapered femoral stem.

Retrospective study including 91 primary THAs in patients ≥70-years old using a triple-tapered femoral stem, between September 2017 and July 2024. Primary outcomes included intraoperative or post-operative periprosthetic fractures and subsidence of the femoral stem. Subsidence was measured on x-rays as the distance between the most proximal aspect of the greater trochanter and the shoulder of the femoral stem.

A total of 91 patients were included, with no periprosthetic fractures observed intraoperatively or post-operatively. The average femoral stem subsidence at 6-weeks post-operative was 1.1 mm (std dev, 0.9) compared to baseline post-operative imaging. At that time point three patients had subsidence ≥3 mm, with no clinically significant symptoms. There was one prosthetic joint infection requiring revision and three superficial surgical site infections. The overall average follow-up time was 12.5 months (std dev, 12.7).

In this study, we found low rates of subsidence and no periprosthetic fractures following primary THA with triple-taper stems in patients ≥70-years old. Of note, no revision surgeries were performed for mechanical failure.

Keywords

Periprosthetic fracture

Subsidence

Total hip arthroplasty

Triple-taper

Femoral stem

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1 Introduction

The use of cemented femoral components in total hip arthroplasty (THA) is gaining popularity in patients over 70-years old due to some reports of high rates of early failure and periprosthetic fractures (PPF) associated with cementless implants.^1–3 The incidence of PPF in this age group has been reported at 0.2 % with cemented versus 1.5 % with cementless implants.¹ This high rate of PPF leads to increased patient morbidity and substantial costs to the healthcare system, with complication rates up to 45 % seen following reoperation for PPF.⁴

The type of stem, in addition to its fixation technique, has been shown to be related to the risk of PPF and femoral stem subsidence.⁵ Recent advances in implant designs have been aimed at reducing these adverse outcomes, with collared femoral stems demonstrating lower rates of stem subsidence compared to collarless stems.⁶ With the more recent advent of the triple-tapered stem, studies have demonstrated good clinical outcomes of this design and outcomes comparable to double-tapered stems.⁷^,⁸ These studies have reported rates of PPF around 1.4 % and an average one-year subsidence of 0.75 mm with the use of triple-tapered stems.⁹

While recent studies have compared the utility and outcomes of triple-tapered stems to other prostheses, there remains a paucity of literature evaluating the use of a collared triple-tapered stem in patients strictly ≥70-years old, a population known to be at higher risk for complications. This study aims to evaluate the post-operative outcomes, particularly rates of periprosthetic fractures and femoral stem subsidence, in patients ≥70-years old who underwent a cementless primary THA with the use of a collared triple-tapered stem.

2 Methods

2.1

2.1 Patient selection

Following Institutional Review Board (IRB) approval, a retrospective chart review of primary THAs performed by two arthroplasty-trained surgeons at a single institution from September 2017 to July 2024 was conducted. CPT code 27,130 was used for initial patient extraction, followed by chart review to ensure inclusion and exclusion criteria were met. Inclusion criteria included patient age ≥70-years old, use of a triple-tapered stem (Actis, DePuy Synthes, Warsaw, IN, USA), and osteoarthritis being the primary indication for surgery. Patients with less than 6-weeks follow-up or with incomplete imaging were excluded (n = 34). Following exclusions, 91 primary THAs were included in the study. All operations were performed using cementless components, with 85 cases done via a direct anterior approach and 6 done via a posterolateral approach.

2.1.1

2.1.1 Variables of interest

Patient demographics including age, sex, race/ethnicity, body mass index (BMI), tobacco use, hypertension, diabetes mellitus, and follow-up time were collected via chart review. Comorbidities were analyzed in the Charlson Comorbidity Index (CCI). Post-operative outcomes assessed included intraoperative or post-operative periprosthetic fractures, superficial infection, prosthetic joint infection, hip dislocation, revision surgery, aseptic loosening, and subsidence of the femoral stem. Subsidence was determined on radiography in Picture Archiving and Communication System (PACS) software by measuring the distance between the proximal portion of the greater trochanter and the shoulder of the femoral stem parallel to a longitudinal line through the stem (Fig. 1). Measurements were made on immediate post-operative and 6-weeks post-operative x-rays. Subsidence was evaluated numerically and categorically, with significant subsidence defined as ≥3 mm.

3 Results

3.1

3.1 Patients

A total of 91-patients ≥70-years old who underwent a primary THA with a triple-tapered femoral stem were identified during the enrollment period (September 2017 to July 2024). Of these patients, a majority (60.4 %) were female, with an average age of 76.0 years (std dev, 5.0). The minimum follow-up time was six-weeks, with an average follow-up time of 12.5 months (std dev, 12.7). Common comorbidities included being overweight with an average BMI of 29.2 (std dev, 5.5) and hypertension (72.5 %). The average CCI was 4.2 (std dev, 1.6) (Table 1).

Table 1 Baseline demographics of study population (n = 91).

	THA Cohort n = 91
Average Age at THA (years)	76.0 (5.0)
Average Follow-up (months)	12.5 (12.7)
GenderFemaleMale	60.4 % (55)39.6 % (36)
Race/EthnicityCaucasianAfrican AmericanHispanicOther	74.7 % (68)14.3 % (13)9.9 % (9)1.1 % (1)
Average Charlson Comorbidity Index	4.2 (1.6)
Body Mass Index (BMI)	29.2 (5.5)
Tobacco UseCurrentFormerNever	5.5 % (5)46.2 % (42)48.4 % (44)
Hypertension (% Yes)	72.5 % (66)
Diabetes Mellitus (% Yes)	22.0 % (20)
Average Length of Hospital Stay (days)	2.6 (1.9)

3.2

3.2 Outcomes following total hip arthroplasty

There were no intraoperative or post-operative femoral fractures observed in the study population. One patient did receive prophylactic cerclage wires intraoperatively due to a damaged piece of anterior calcar, however, there were no propagating fracture lines witnessed. There were three patients with superficial surgical site infections, two managed non-operatively with oral antibiotics, the third requiring return to the operating room for irrigation and debridement of the superficial tissues. There was one case of prosthetic joint infection requiring revision surgery (Table 2).

Table 2 Post-operative outcomes following primary THA (n = 91).

	THA Cohort n = 91
Periprosthetic Fracture	0 % (0)
Average Subsidence of Femoral Stem at 6-weeks Post-Operative (mm)	1.1 (0.9)
Subsidence≤3 mm≥3 mm≥5 mm	96.7 % (88)3.3 % (3)0 % (0)
Superficial Surgical Site Infection	3.3 % (3)
Prosthetic Joint Infection	1.1 % (1)
Hip Dislocation	0 % (0)
Revision Surgery	1.1 % (1)

Mean femoral stem subsidence was 1.1 mm (std dev, 0.9) at 6-weeks post-operative compared to baseline post-operative imaging. Three patients had subsidence greater than 3 mm at this time point that subsequently stabilized. No patients had subsidence ≥5 mm (Table 2). Of note, the 34 patients who were excluded for either incomplete post-operative imaging or less than 6-weeks follow-up did not sustain an intraoperative fracture and to our knowledge did not have an early post operative fracture.

4 Discussion

Elderly patients represent a population at increased risk for post-operative complications following THA, primarily periprosthetic fractures and revision due to mechanical failure.^1–3 Advances in prosthesis design have sought to prevent these adverse outcomes, with collared, triple-tapered stems representing a newer implant with comparable outcomes to the more familiar double-tapered stems.⁷^,⁸ In this study, we assessed the post-operative outcomes of primary THA with a triple-tapered stem in patients ≥70-years old. Within the study population, no periprosthetic fractures were observed intraoperatively or post-operatively. At 6-weeks post-operative, a majority of the patients had less than 3 mm of femoral stem subsidence, with no clinically significant subsidence observed. No revision surgeries were performed for mechanical failure.

This study aligns with current literature by seeking to reduce post-operative complications following THA. Tyrpenou et al. recently conducted a retrospective study evaluating the long-term outcomes of cementless collarless triple-tapered femoral stems in THA, with excellent implant survivorship seen at 15-years post-operatively.¹⁰ Their results demonstrated improvement in patient function and low rates (2.28 %) of revision surgery, with over half of those revision surgeries performed for PPF and none for aseptic loosening.¹⁰ Their average patient age was 49.6 years, however, leaving room to focus specifically on the higher risk elderly population as described in this study.¹⁰ Of note, Tyrpenou et al. evaluated an older stem, with the Actis stem used in our study representing a newer design primarily used in anterior-approach THA.¹⁰

Femoral stem subsidence measurement on early radiographs can be used to predict the likelihood of long-term implant loosening and ultimate failure, with most clinically significant subsidence seen within 6 to 8-weeks post-operatively.¹¹ Subsidence ≥3–5 mm has been used by multiple studies to define radiographically significant subsidence, with clinical correlation necessary.^12–14 In our study, no patients achieved greater than 5 mm of subsidence at 6-weeks post-operatively, with most patients falling under 3 mm. The three patients with subsidence ≥3 mm demonstrated no clinical symptoms. Prior studies have found factors including elevated BMI and increased age to be associated with increased risk of subsidence, factors that were common within our study population¹²^,¹⁵

The lower rate of fractures is attributed to a few qualities of this stem. The medial collar has been shown to improve stability, dissipate hoop stress, improve rotational control, and decrease subsidence.¹⁶^,¹⁷ A cadaveric study conducted by Demey et al. reported greater stability with uncemented collared stems versus uncemented collarless stems, with the collared stems able to withstand greater forces before subsidence and fractures occurred.¹⁷ The “fit and fill” and tapered style of the stem aids in both short-term and long-term stability, reducing the risk of fractures.¹⁸ The composition of the stem is grit-based distally and coated in hydroxyapatite, helping to promote fixation.¹⁹ Lastly, the stem is inserted with a hybrid broach, combining extraction and compaction technology.¹⁹ This places less stress on the bone while still ensuring adequate fit and preservation of the patient's anatomy.¹⁹ Early studies have demonstrated reduced revision rates with the use of an Actis stem when compared to other implants, with a cumulative revision rate of 1.08 % at three-years post-operative reported in the literature.¹⁸

The retrospective design of this study inherently presents the potential for bias, limiting this study. Due to this study design a standard method of taking the radiographs could not be used which may have allowed for more accurate measurements. Furthermore, all of the radiographic measurements were performed by the same person to limit potential variability; however, this introduces the risk of intra-observer errors. Additional limitations include only obtaining subsidence measurements at 6-weeks post-operative. While the overall average follow-up period for our patients was one-year, there was variability in the timing of post-operative x-rays. Thus, to maintain consistency we chose to only evaluate subsidence at the 6-week mark, which is supported by previous studies that have reported that most clinically significant subsidence occurs within the 6 to 8-weeks post-operative period.¹¹ Nonetheless, having additional subsidence measurements would have strengthened this study. Finally, during this time period there were patients over the age of 70 with hip fracture treated with a cemented prosthesis, so this should not be treated as a consecutive series of patients over the age of 70 with any arthroplasty. There remains a low threshold to utilize a cemented stem in the fracture population at our institution. During the time period of our study, there were an additional 30 primary THAs performed for OA in patients ≥70-years old with alternative stems, of which five were cemented. Thus, the use of cemented components in select cases may still be necessitated.

To our knowledge this paper is the largest study evaluating outcomes following primary THA with a triple-tapered stem in patients ≥70-years old. These results demonstrate low rates of complications with the use of cementless implants in a population known to be at higher risk for PPF and subsidence. Further large-scale studies are warranted.

5 Conclusion

This study found low rates of subsidence at 6-weeks post-operative following primary total hip arthroplasty with a triple-tapered stem in patients ≥70-years old. No patients had periprosthetic fractures, clinically significant subsidence, or revision surgery due to mechanical failure.

CRediT authorship contribution statement

Whisper Grayson: Investigation, Methodology, Data curation, Writing – original draft, Writing – review & editing. Carlo Eikani: Investigation, Writing – review & editing. Nicholas M. Brown: Conceptualization, Supervision, Writing – review & editing. Daniel Schmitt: Conceptualization, Supervision, Writing – review & editing.

Consent

Institutional Review Board approval was submitted and received for this study, and the manuscript is not submitted elsewhere for publication consideration.

Ethical review committee statement

The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and has been carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act (HIPAA).

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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