Cortical hypertrophy with a short, curved uncemented hip stem does not have any clinical impact during early follow-up

Background: Short stems have become more and more popular for cementless total hip arthroplasty in the past few years. While conventional, uncemented straight stems for primary total hip arthroplasty (THA) have shown high survival rates in the long term, it is not known whether uncemented short stems represent a reasonable alternative. As cortical hypertrophy has been reported for short stems, the aim of this study was to determine the radiographic prevalence of cortical hypertrophy and to assess the clinical outcome of a frequently used short, curved hip stem. Methods: We retrospectively studied the clinical and radiographic results of our first 100 consecutive THAs (97 patients) using the Fitmore® hip stem. Mean age at the time of index arthroplasty was 59 years (range, 19 – 79 years). Clinical outcome and radiographic results were assessed with a minimum follow-up of 2 years, and Kaplan-Meier survivorship analysis was used to estimate survival for different endpoints. Results: After a mean follow-up of 3.3 years (range, 2.0 – 4.4 years), two patients (two hips) had died, and three patients (four hips) were lost to follow-up. Kaplan-Meier analysis estimated a survival rate of 100 % at 3.8 years, with revision for any reason as the endpoint. No femoral component showed radiographic signs of loosening. No osteolysis was detected. Cortical hypertrophy was found in 50 hips (63 %), predominantly in Gruen zone 3 and 5. In the cortical hypertrophy group, two patients (two hips; 4 %) reported some thigh pain in combination with pain over the greater trochanter region during physical exercise (UCLA Score 6 and 7). There was no significant difference concerning the clinical outcome between the cortical hypertrophy and no cortical hypertrophy group. Conclusions: The survival rate and both clinical and the radiographic outcome confirm the encouraging results for short, curved uncemented stems. Postoperative radiographs frequently displayed cortical hypertrophy but it had no significant effect on the clinical outcome in the early follow-up. Further clinical and radiographic follow-up is necessary to detect possible adverse, long-term, clinical effects of cortical hypertrophy

Primary rotational stability of various megaprostheses in a biomechanical sawbone model with proximal femoral defects extending to the isthmus.

Fixation of proximal femoral megaprostheses is achieved in the diaphyseal isthmus. We hypothesized that after extended bone resection including the proximal part of the isthmus a reduced length of fixation will affect the stability and fixation characteristics of these megaprostheses. The aim of this study was to analyze in a validated sawbone model with extended proximal femoral defects which types of implants have sufficient primary stability to allow osteointegration and to describe their fixation characteristics.Four different cementless megaprostheses were implanted into 16 Sawbones with an AAOS type III defect after resection 11 cm below the lesser trochanter involving the proximal isthmus. To determine the primary implant stability relative micromotions between bone and implant were measured in relation to a cyclic torque of 7Nm applied on the longitudinal axis of the implant. We determined the fixation characteristics of the different implant designs by comparing these relative micromotions along the longitudinal stem axis.In the tested sawbones all studied implants showed sufficient primary stability to admit bone integration with relative micromotions below 150 µm after adapting our results to physiologic hip joint loadings. Different fixation characteristics of the megaprostheses were determined, which could be explained by their differing design and fixation concepts.Cementless megaprostheses of different designs seem to provide sufficient primary stability to bridge proximal femoral defects if the diaphyseal isthmus is partially preserved. In our sawbone model the different implant fixation patterns can be related to their stem designs. No evidence can be provided to favor one of the studied implants in this setting. However, femoral morphology is variable and in different isthmus configurations specific implant designs might be appropriate to achieve the most favorable primary stability, which enables bone integration and consequently long term implant stability

Effect of bone quality and quantity on the primary stability of dental implants in a simulated bicortical placement

Objectives!#!Conventional dental implants inserted in the molar region of the maxilla will reach into the sinus maxillaris when alveolar ridge height is limited. When surgery is performed without prior augmentation of the sinus floor, primary stability of the implant is important for successful osseointegration. This study aimed at identifying the impact of bone quality and quantity at the implantation site on primary implant stability of a simulated bicortical placement.!##!Materials and methods!#!In our in vitro measurements, bone mineral density, total bone thickness and overall cortical bone thickness were assessed by micro-computed tomography (μCT) of pig scapulae, which resembled well the bicortical situation found in human patients. Dental implants were inserted, and micromotion between bone and implant was measured while loading the implant with an axial torque.!##!Results!#!The main findings were that primary implant stability did not depend on total bone thickness but tended to increase with either increasing bone mineral density or overall cortical bone thickness.!##!Clinical relevance!#!Limited bone height in the maxilla is a major problem when planning dental implants. To overcome this problem, several approaches, e.g. external or internal sinus floor elevation, have been established. When planning the insertion of a dental implant an important aspect is the primary stability which can be expected. With other factors, the dimensions of the cortical bone might be relevant in this context. It would, therefore, be helpful to define the minimum thickness of cortical bone required to achieve sufficient primary stability, thus avoiding additional surgical intervention

Used segmental AAOS defects of the proximal femur.

<p>The femoral isthmus region has been colored.</p

Schematic cross sections of all four stem designs in comparison.

<p>Schematic cross sections of all four stem designs in comparison.</p

Rotational stability of a) Megasystem-C, b) MUTARS, c) GMRS and d) Segmental System in mdeg/Nm.

<p>Rotational stability of a) Megasystem-C, b) MUTARS, c) GMRS and d) Segmental System in mdeg/Nm.</p

Measurement points of the implant (orange; #1-#4) and bone (blue; #5-#10) at different measuring levels.

<p>Measurement points of the implant (orange; #1-#4) and bone (blue; #5-#10) at different measuring levels.</p

Tibial revision knee arthroplasty with metaphyseal sleeves: The effect of stems on implant fixation and bone flexibility

<div><p>Introduction</p><p>Revision total knee arthoplasty often requires modular implants to treat bone defects of varying severity. In some cases, it may not be clear which module size and implant combination (e.g. sleeve and stem) should be chosen for a specific defect. When balancing implant stability and osseointegration against stress-shielding, it is important to choose an appropriate implant combination in order to match the given level of bone loss. Therefore, the necessity of stems in less extensive tibial defects and the advantage of different stems (lengths and stiffnesses) in combination with large metaphyseal sleeves on implant fixation and bone flexibility using a modular tibial revision knee system, were analyzed.</p><p>Materials and methods</p><p>Four different stem combinations for a tibial revision implant (Sigma TC3, DePuy) were compared to an intact bone. Standardized implantation with <i>n</i> = 4 synthetic tibial bones was performed after generating an Anderson Orthopaedic Research Institute (AORI) Type T1 bone defect. Axial torques around the longitudinal stem axis and varus-valgus torques were separately applied to the implant. Micromotions of bone and implant were tracked using a digital image correlation system to calculate relative micromotions at the implant-bone-interface and bone deformation.</p><p>Results</p><p>Overall, using stems reduced the proximal micromotions of tray and sleeve compared to no stem, while reducing bone deformation proximally at the same time, indicating some potential for proximal stress-shielding compared to no stem. The potential for increased proximal stress-shield due to reduced proximal deformation appeared to be greater when using the longer stems. The location of lowest relative micromotions was also more distal when using long stems as opposed to short stems. A short stem (especially a smaller diameter short stem which still achieves diaphyseal fixation) displayed less potential for stress-shielding, but greater bone deformation distal to the tip of the stem than in the natural model.</p><p>Discussion</p><p>In the case of tibial revision implants with metaphyseal sleeves in a simple fully contained Type I defect, the absence of a stem provides for more natural bone deformation. However, adding a stem reduces overall relative micromotions, while introducing some risk of proximal stress-shielding due to increased diaphyseal fixation. Increasing stem length intensifies this effect. Short stems offered a balance between reduced micromotions and more proximal bone deformation that reduced the potential for stress-shielding when compared to long stems. A short stem with slightly smaller diameter (simulating a less stiff stem which still has diaphyseal fixation) increased the proximal bone deformation, but also tended to increase the bone deformation even further at the distal stem’s tip.</p><p>Conclusion</p><p>In conclusion, further investigation should be conducted on fully contained Type I defects and the addition of a stem to offer better initial stability, taking into account stem length (i.e. shorter or more flexible stems) to support metaphyseal fixation and allowing bending found in intact bone. In addition, further study into more extensive tibial defects is required to determine if the stability/micromotion trends observed in this study with stems and sleeves in Type I defects still apply in cases of extensive proximal bone loss.</p></div

Simulated AORI Type I resection using a template, located 5 mm distal to the medial plateau.

<p>Simulated AORI Type I resection using a template, located 5 mm distal to the medial plateau.</p

Measured relative micromotions at the bone sections Δ_b1,b2 to Δ_b5,b6 are shown for intact bone Group E and for all implant groups (A-D) described as means and standard deviation (±SD).

<p>The applied varus-valgus torque is separated into lateral and medial load condition to analyze bending bone deformation.</p