Femoral Stem Fracture in Hip Revision Arthroplasty: A Systematic Literature Review of the Real-World Evidence

Abstract

Background Total hip arthroplasty (THA) presents as an excellent treatment for the osteoarthritic hip, demonstrating good survival rates. However, aseptic loosening and infection are the main causes of operative revision. The methods used in revision surgery are non-modular or modular THA implants. In addition to the abovementioned revision reasons for THA, this treatment could be associated with the possibility of femoral stem fracture, especially in the modular system. The topic of material failure has been focused on in the public media. The question arises as to how such media reports correlate with the published literature. The observed mentioned number of cases concerning a femoral stem fracture vary between one single case and up to 18.5% within a clinical study, thus presenting an inhomogeneous data situation with a large span. The specific aim of this systematic review is to establish facts and clarify the number of unforeseen events of a femoral stem fracture based on peer review articles and registry data. This clarification is important to us, as these media reports have led to uncertainty among patients.

Methods A systematic review was performed in accordance with the PRISMA statement. Peer review articles in English and German, presenting original articles, meta-analyses, or case reports, were searched from the turn of the millennium up to December 2019. Only articles that reported a femoral stem component fracture, with content of clinical data as well as register data, were included. Relevant papers published after the defined research time frame were taken into account within the discussion.

Results In total, 218 fractures of a femoral stem (141 primary and 77 revision THA) component could be identified within the selected literature. Most cases of a femoral stem fracture occurred in the modular THA implants compared to the non-modular stems. Regarding revision THA, in summary, 77 implants, presenting 23 non-modular and 54 modular implants, failed by means of femoral stem fracture. A review of 11 National Joint Registries shows a revision rate between 0.04 and 0.05% in only 2 registers according to the specific subject of a femoral stem fracture. For the remaining 9 registers, however, detailed information is lacking and only nonspecific information such as a generic “implant failure” or “other reason” (which can cover a multitude of causes) is supplied.

Conclusion A femoral stem fracture presents a devastating complication for the patient, the surgeon as well as for the manufacturer of the implant. Modular THA implants play an increasingly valuable role concerning restoration of individual anatomy in modern THA revision surgery, especially within complex cases. Regarding revision procedures, data suggests a lower risk of femoral stem fracture for modular implants compared to primary procedures, while the risk of fracture for non-modular implants seems to increase during revision. Ultimately, it cannot be proven whether this is actually applicable, since the absolute number of implanted prosthesis systems is not known. Various implant-, patient-, and surgeon-related factors may lead to these reported femoral stem fractures. However, this systematic review suggests that this is, in general, a rare complication.

Zusammenfassung

Einleitung Die Hüftendoprothetik stellt eine ausgezeichnete Behandlungsoption der Hüftgelenksarthrose dar und weist gute Langzeitüberlebensraten der Implantate auf. Aseptische Lockerungen und Infektionen sind die Hauptursachen für eine Revision des primären Hüftgelenkersatzes. Die in der Revisionschirurgie verwendeten Implantatkonzepte sind als nicht modulare oder modulares Hüftendoprothesensystem verfügbar. Neben den genannten Revisionsgründen wird in der modularen Revisionsendoprothetik vereinzelt über gebrochene, femorale Schaftkomponenten berichtet. Das Thema des Materialversagens in der Endoprothetik ist in Fokus der Medien gerückt. Es stellt sich die Frage, wie solche Medienberichte mit der veröffentlichten Literatur korreliert. Die genannten Fallzahlen femoraler Schaftbrüche variieren von Einzelfällen bis zu 18,5% in klinischen Studien. Ziel der Arbeit ist es, Daten aus der Literatur und Registern zu sammeln, um eine möglichst realitätsnahe Frakturrate für die femorale Schaftkomponente zu ermitteln. Die Klärung der Sachlage ist wichtig, da derartige Medienberichte zur Verunsicherung der Patienten führen.

Material und Methode Gemäß den PRISMA-Richtlinien wurde eine systematische Literaturrecherche durchgeführt. Peer-Review-Artikel in englischer und deutscher Sprache wurden im Zeitraum Januar 2000 bis Dezember 2019 recherchiert. Neben Registerdaten wurden nur wissenschaftliche Artikel mit klinischen Daten, die unterschiedliche femorale Schaftbrüche abhandelten, eingeschlossen. Relevante Beiträge, die nach dem definierten Recherchezeitraum veröffentlicht wurden, sind in der Diskussion dieser Arbeit berücksichtigt.

Ergebnisse Insgesamt konnten 218 Frakturen femoralen Schaftkomponenten (141 primäre und 77 Revisionsendoprothesensysteme) gezählt werden. Die meisten Schaftbrüche traten bei modularen Systemen auf. Bei den 77 Revisionsendoprothesensystemen brachen anteilig 23 nicht-modulare und 54 unterschiedliche modulare Implantate. Die Durchsicht von insgesamt 11 Endoprothesenregistern ergab, dass in nur 2 Registern die Revisionsrate aufgrund femoralen Schaftbrüche beschrieben wurde, die zwischen 0,04% und 0,05% lag. Bei den verbleibenden 9 Registern fehlen detaillierte Angaben. Hier werden nur unspezifische Informationen angegeben, wie z. B. ein allgemeines „Implantatversagen“ (das eine Vielzahl von Implantatkomponenten umfassen kann) oder solche Ereignisse werden unspezifizierend unter der Kategorie „anderer Revisionsgrund“ subsummiert.

Diskussion Der femorale Schaftbruch stellt für den Patienten, den Chirurgen und den Implantathersteller eine gravierende Komplikation dar. Modulare Systeme spielen in der modernen Hüftrevisionschirurgie, insbesondere in komplexen Situationen, eine immer wertvollere Rolle. Die modulare Revisions-Hüftendoprothetik scheint ausweislich der vorgelegten Analyse ein geringeres Risiko für einen femoralen Schaftbruch im Vergleich zu modularen Systemen in der Primärversorgung aufzuweisen, während das Frakturrisiko beim nicht modularen Implantat in der Revisionsendoprothetik einen erhöhten Absolutwert zeigte. Ob dies tatsächlich zutreffend ist, kann letztendlich nicht belegt werden, da die absoluten Zahlen der implantierten Prothesensysteme nicht bekannt sind. Unterschiedlichste implantat-, patienten- und chirurgisch-assoziierte Faktoren können zum femoralen Schaftbruchs führen. Die Daten dieser systematischen Literaturrecherche zeigen jedoch, dass der femoralen Schaftbruch eine eher selten auftretende Komplikation ist.

Key words

femoral stem - stem fracture - systematic review - total hip arthroplasty - revision hip arthroplasty

Schlüsselwörter

femorale Schaft - Schaftbruch - systematisches Review - Hüftendoprothetik - Hüftrevision

Publication History

Article published online:
13 April 2021

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