Aims. United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures. Methods. A retrospective review was conducted of all patients who underwent revision THA (rTHA) for periprosthetic UCS B2 and B3 periprosthetic fracture who received a single design monoblock fluted tapered titanium stem at two large, tertiary care, academic hospitals. A total of 72 patients met inclusion and exclusion criteria (68 UCS B2, and four UCS B3 fractures). Primary outcomes of interest were radiological stem subsidence (> 5 mm), radiological osseointegration, and fracture union. Sub-analysis was also done for 46 patients with minimum one-year follow-up. Results. For the total cohort, stem osseointegration, fracture union, and stem subsidence were 98.6%, 98.6%, and 6.9%, respectively, at latest follow-up (mean follow-up 27.0 months (SD 22.4)). For patients with minimum one-year of follow-up, stem osseointegration, fracture union, and stem subsidence were 97.8%, 97.8%, and 6.5%, respectively. Conclusion. Monoblock fluted stems can be an acceptable modality for the management of UCS B2 periprosthetic fractures in rTHAs due to high rates of stem osseointegration and survival, and the low rates of stem subsidence, and revision. Further research on the use of this stem for UCS B3 periprosthetic fractures is warranted to determine if the same conclusion can be made for this fracture pattern. Cite this article: Bone Jt Open 2023;4(8):551–558

We had previously reported on early outcomes on a new fluted, titanium, monobloc stem with a three degree taper that has been designed for challenging femoral reconstruction in the setting of extensive bone loss. The aim of this study was to report its mid-term clinical and radiographic outcomes. This is a retrospective review of prospectively collected data carried out at a single institution between Jan 2017 and Dec 2019. 85 femoral revisions were performed using a new tapered, fluted, titanium, monobloc (TFTM) revision stem. Complications, clinical and radiographic data were obtained from medical records and a locally maintained database. Clinical outcomes were assessed using the Oxford Hip Score (OHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). All post-operative radiographs were analysed for subsidence, osteolysis and femoral cortical bone remodelling. Mean follow-up was 60 months (range 28–84 months). Subsidence of 1.2 mm was noted in one patient. No cases of clinically significant subsidence (10 mm) were observed. At final follow-up, a statistically significant improvement was noted in functional outcome scores. The mean OHS preoperatively and at final follow-up were 24 (SD 13) and 42 (SD15). p = 0.04 mean difference 18 (95% CI 15–22). The mean WOMAC scores preoperatively and at final follow-up were 62 (SD23) and 88 (SD7) respectively (p < 0.001, mean difference 26; 95% CI 21–34). No stem fractures were noted within the follow-up period. Two patients had revision of the stem's one for infection and another for persistent pain. Positive mid-term clinical and radiological outcomes have been observed with this tapered, fluted, titanium, monobloc stem. Based on these results, this implant may be considered as a viable option in the majority of uncemented femoral revisions

Aims. The risk of mechanical failure of modular revision hip stems is frequently mentioned in the literature, but little is currently known about the actual clinical failure rates of this type of prosthesis. The current retrospective long-term analysis examines the distal and modular failure patterns of the Prevision hip stem from 18 years of clinical use. A design improvement of the modular taper was introduced in 2008, and the data could also be used to compare the original and the current design of the modular connection. Methods. We performed an analysis of the Prevision modular hip stem using the manufacturer’s vigilance database and investigated different mechanical failure patterns of the hip stem from January 2004 to December 2022. Results. Two mechanical failure patterns were identified: fractures in the area of the distal fluted profile (distal stem fracture) and failure of the modular taper (modular fracture). A failure rate of 0.07% was observed for distal stem fracture, and modular fracture rates of 1.74% for the original and 0.013% for the current taper design. Conclusion. A low risk of mechanical failure for both fracture types was observed compared to other known complications in revision hip arthroplasty. In addition, the data show that a design change did significantly reduce the risk of a modular fracture. Cite this article: Bone Joint J 2024;106-B(2):151–157

There is a paucity of long-term data on modular fluted tapered (MFT) stems for two-stage reimplantation following periprosthetic joint infection (PJI). The purpose of this study was to evaluate implant survivorship, radiographic results, and clinical outcomes in a large cohort of reimplantation THAs using MFT stems. We identified 236 reimplantation THAs from a single tertiary care academic institution from 2000 to 2020. Two designs of MFT stems were used as part of an established two-stage exchange protocol for the treatment of PJI. Mean age at reimplantation was 65 years, mean BMI was 32 kg/m. 2. , and 46% were female. Median stem diameter was 19 mm, and median stem length was 195 mm. Mean follow-up was 7 years. A competing risk model accounting for death was utilized. The 15-year cumulative incidence of any revision was 24%. There were 48 revisions, with the most common reasons being dislocation (n=25) and PJI (n=16). The 15-year cumulative incidence of any reoperation was 28%. Only 13 revisions involved the fluted tapered portion of the component (FTC), for a 15-year cumulative incidence of any FTC revision of 8%. Only 2 FTCs were revised for aseptic loosening, resulting in a 15-year cumulative incidence of FTC revision for aseptic loosening of 1%. Stem subsidence >5 mm occurred in 2% of unrevised cases, and all stems were radiographically stable at most recent follow-up. Mean HHS was 77 at most recent follow-up. This series demonstrated that MFT stems were durable and reliable even in the setting of two-stage reimplantation for infection. While the incidence of aseptic loosening was very low, the incidence of any revision was 24% at 15 years, primarily caused by dislocation and recurrent PJI. Level of Evidence: IV

Tapered fluted grit-blasted modular stems have now become established as a successful method of femoral revision. The success of these stems is predicated on obtaining axial stability by milling the femur to a cone and then inserting the tapered prosthesis into that cone. Torsional stability is gained by flutes that cut into the diaphysis. By having modular proximal segments of different lengths, the leg length, offset, and anteversion can be adjusted after the distal stem is fixed. This maximises the chance for the stem to be driven into the canal to whatever level provides maximum stem stability. Modular fluted tapered stems have the potential benefits of being made of titanium and hence being both bone friendly and also having a modulus of elasticity closer to that of bone. They have a well-established high rate of fixation. Drawbacks include the risk of fracture of modular junctions and tapers, and difficulty of extraction. The indications for the use of these implants vary among surgeons, but the implants are suitable for use in a wide variety of bone loss categories. Non-modular fluted tapered stems also can gain excellent fixation, but are less versatile and in most practices are used for selected simpler revisions. Results from a number of institutions in North America and Europe demonstrate high rates of implant fixation. In a recently published paper from Mayo Clinic, the 10-year survivorship, free of femoral aseptic loosening revision, of a modular fluted tapered stem was 98% and the stem performed well across a wide range of bone deficiencies. The technique of implantation will be described in a video during the presentation

Local anatomical abnormalities vary in congenital hip disease patients. Authors often present early to mid-term total hip arthroplasty clinical outcomes using different techniques and implants randomly on patients with different types of the disease, making same conclusions difficult. We report long term outcomes (13 to 23 years) of the treatment of low and high dislocation cases (separately) with total hip arthroplasty using TM technology acetabular cups (Implex initially and then Zimmer) and short fluted conical (Zimmer) femoral stems. From 2000 to 2010, 418 congenital hip disease hip joints were treated in our department with total hip arthroplasty. According to Hartofilakidis et al's classification, 230 hips had dysplasia, 101 low dislocation, (group A) and 87 high dislocation (group B). Pre-operative and post-operative values, at regular intervals, of HHS, SF-12, WOMAC, OHS and HOOS were available for all patients. Patient, surgeon and implant related failures and complications were recorded for all patients. In all cases an attempt was made to restore hip center of rotation. In group A the average lengthening was 2.8 cm (range: 1 to 4.2) and in group B 5.7 cm (range: 4.2 to 11). In both groups, no hips were revised due to aseptic loosening of either the acetabular cup or the femoral stem. In group A, a cumulative success rate of 95.6% (95% confidence interval, 92.7% – 97.4%) and in group B a cumulative success rate of 94.8% (95% confidence interval, 92.6%–96.9%) was recorded, at 20 years, with revision for any reason as an end point. No s.s. differences were found between groups when mean values of HHS, SF-12, WOMAC and OKS were compared. Satisfactory long-term clinical outcomes can be achieved in treating different types of congenital hip disease when appropriate surgical techniques combined with “game changing” implants are used

We sought to determine the short to medium-term clinical and radiographic outcomes using a short stem in young adults with a proximal femoral deformity (PFD). We prospectively studied 31 patients (35 hips) with PFDs treated with an uncemented primary THA using a short stem with cervicometaphyseal fixation between 2011–2018. There were 19 male (23 hips) and 12 female (12 hips) patients, with a mean BMI of 26.7±4.1 kg/m. 2. Twelve cases had a previous surgical procedure, and six of them were failed childhood osteotomies. Mean age of the series was 44±12 years, mean follow-up was 81±27 months and no patients were lost to follow-up. PFDs were categorized according to a modified Berry´s classification. Average preoperative leg-length discrepancy (LLD) was −16.3 mm (−50 to 2). At a mean time of 81 months of follow-up, survival rate was 97% taking revision of the stem for any reason and 100% for aseptic loosening as endpoints. No additional femoral osteotomy was required in any case. Average surgical time was 66 minutes (45 to 100). There was a significant improvement in the mHHS score when comparing preoperative and postoperative values (47.3±10.6 vs. 92.3±3.7, p=0.0001). Postoperative LLD was in average 1 mm (−9 to 18) (p=0.0001). According to Engh's criteria, all stems were classified as stable without signs of loosening. Postoperative complications included 1 pulmonary embolism, 1 neurogenic sciatic pain, 1 transient sciatic nerve palsy that recovered completely after six months, and 2 acute periprosthetic joint infections. One patient suffered a Vancouver B2 periprosthetic femoral fracture 45 days after surgery and was revised with a modular distally fixed uncemented fluted stem. A type 2B short stem evidenced promising outcomes at short to medium-term follow up in young adult patients with PFDs, avoiding the need for corrective osteotomies and a revision stem

Subsidence remains a concern when utilizing modern tapered fluted titanium (TFT) femoral stems and may lead to leg length discrepancy, impingement, instability and failure to obtain stem osseointegration. This study aims to compare stem subsidence across three modern TFT stems. Our secondary aim was to investigate the influence of bicortical contact or ‘scratch fit’ on subsidence, as well as the role of intraoperative imaging in maximizing this bicortical contact and preventing stem subsidence. A retrospective review of 271 hip arthroplasties utilizing modern TFT stems in a single institution was performed. Three stem designs were included in the analysis: one monoblock TFT stem (n=91) and two modular TFT stems (Modular A [n=90]; Modular B [n=90]). Patient demographics, Paprosky femoral bone loss classification, bi-cortical contact, utilization of intra-operative imaging and stem subsidence (comparison of initial post-operative radiograph to the latest follow up radiograph - minimum three months) were recorded. There was no statistically significant difference in the amount of subsidence between the three stems (Monoblock: 2.33mm, Modular A: 3.43mm, Modular B: 3.02mm; p=0.191). There was no statistical difference in subsidence >5mm between stems (Monoblock: 9.9%, Modular A: 22.2%, Modular B: 16.7%). Subgroup analysis based on femoral bone loss grading showed no difference in subsidence between stems. Increased bicortical contact was strongly associated with reduced subsidence (p=0.004). Intra-operative imaging was used in 46.5% (126/271) of cases; this was not correlated with bicortical contact (p=0.673) or subsidence (p=0.521). Across all groups, only two stems were revised for subsidence (0.7%). All three modern TFT stems were highly successful and associated with low rates of subsidence, regardless of modular or monoblock design. Surgeons should select the stem that they feel is most clinically appropriate

For over a decade, modular titanium fluted tapered (TFT) stems have demonstrated excellent clinical success for femoral revision total hip arthroplasty (THA) surgery. The aim of this study was to report the short-term outcomes of a novel modern monoblock TFT stem used for revision and complex primary THA with a minimum of 2 years follow-up. We identified 126 patients who received a single monoblock TFT stem - 26 patients for complex THA (failed fracture fixation) and 100 patients for revision THA. The reasons for revision THA included 40 for previous prosthetic joint infection (PJI), 42 for aseptic loosening, 9 for trunnionosis, 9 for periprosthetic fractures. The Paprosky grading for femoral bone loss at the time of surgery and the measured subsidence of femoral stems at 3 months follow-up were determined. We evaluated the number and indications for re-operations. The mean time from surgery was 3.9 years (range 2.0 to 6.9 years). A paired t-test analysis showed significant improvement from pre-operative versus post-operative clinical outcome scores (p<0.001) for HHS (38.76 +/- 15.24vs. 83.42 +/- 15.38), WOMAC (45.6 ± 19.0 vs. 69.9 ± 21.3) and SF-12 Physical component (31.7 ± 8.1 vs. 37.8 ± 11.3) and SF-12 Mental component (48.2 ± 12.2 vs. 51.6 ± 12.5). The Paprosky grading for femoral bone loss was Grade 1 (3.9%), Grade 2 (35.7%), Grade 3A (47.6%), Grade 3B (11.1%) and Grade 4 (1.6%) cases. There were 18 re-operations (14.7%) with 13 for PJI (7 treated with implant retention, 6 treated with a two-staged revision), 4 for instability and one for acetabular aseptic loosening. There were no aseptic failures of the stem. This novel modern monoblock TFT stem provided reliable femoral fixation and has increasingly supplanted the use of modular TFT stems for complex primary and revision surgery in our institution

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In 2 studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a match cohort of monoblock cobalt chromium stems. As mentioned, one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction, more recently, at our institution, we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with a monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done with a endofemoral approach. In this approach the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this stem more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

Introduction. As the proximal femoral bone is generally compromised in failed total hip arthroplasty, achievement of solid fixation with a new component can be technically demanding. Clinical studies have demonstrated good medium-term results after revision total hip arthroplasty using modular fluted and tapered distal fixation stems, but, to our knowledge, long-term outcomes have been rarely reported in the literature. The purpose of this study was to report the minimum ten-year results of revision total hip arthroplasty using a modular fluted and tapered distal fixation stem. Materials & Methods. We analyzed 40 revision THAs performed in using a modular fluted and tapered distal fixation stem (Fig. 1) between December 1998 and February 2004. There were 11 men (12 hips) and 28 women (28 hips) with a mean age of 59 years (range, 38 to 79 years) at the time of revision THA. According to the Paprosky classification of femoral defects, 5 were Type II, 24 were Type IIIA, and 11 were Type IIIB. An extended trochanteric osteotomy was carried out in 21 (52%) of the 40 hips. Patients were followed for a mean of 11.7 years (range, 10 to 15 years). Results. The mean Harris hip score improved from 41 points preoperatively to 85 points at the time of the latest follow-up. A total of 4 hips required additional surgery. One hip had two-stage reconstruction due to deep infection, one had liner and head exchange for ceramic head fracture, one had isolated cup re-revision for aseptic loosening, and one had constrained component revision for recurrent dislocation. No repeat revision was performed due to aseptic loosening of femoral stem. There was no stem fracture at the modular junction. Kaplan-Meier survivorship with an end point of stem re-revision for any reason was 98.1% at 11.7 years (Fig. 2), and, for aseptic stem loosening, the best-case scenario was 100% and the worst-case scenario was 91.9% at 11.7 years (Fig. 3). Conclusions. A modular fluted and tapered distal fixation stem continued to provide a reliable fixation at a minimum ten years after revision THA and can therefore be recommended as a promising option for challenging revision situations with femoral bone defects

Periprosthetic fractures (PPF) of the femur following total hip arthroplasty represent a significant complication with a rising incidence. The commonest subtype is Vancouver B2 type, for which revision to a long uncemented tapered fluted stem is a widely accepted management. In this study we compare this procedure to the less commonly performed cement-in-cement revision. All patients undergoing surgical intervention for a Vancouver B2 femoral PPF in a cemented stem from 2008 – 2018 were identified. We collated patient age, gender, ASA score, BMI, operative time, blood transfusion requirement, change in haemoglobin (Hb) level, length of hospital stay and last Oxford Hip Score (OHS). Radiographic analysis was performed to assess time to fracture union and leg length discrepancy. Complications and survivorship of implant and patients were recorded. 43 uncemented and 29 cement-in-cement revisions were identified. There was no difference in patient demographics between groups. A significantly shorter operative time was found in the cement-in-cement group, but there was no difference in transfusion requirement, Hb change, or length of hospital stay. OHS was comparable between groups. A non-significant increase in overall complication rates was found in the revision uncemented group, with a significantly higher dislocation rate. Time of union was comparable and there were no non-unions in the cement-in-cement group. A greater degree of stem subsidence was found in the uncemented group. There was no difference in any revision surgery required in either group. Three patients in the uncemented group died in the perioperative period, compared to none in the cement-in-cement group. With appropriate patient selection, both cement-in-cement and long uncemented tapered stem revision represent appropriate treatment options for Vancouver B2 fractures

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared the modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In 2 studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a match cohort of monoblock cobalt chromium stems. As mentioned one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post-revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction more recently at our institution we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done with an endofemoral approach. In this the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this stem more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

Introduction. Self tapping bone screw has been widely used in the fixation of Arthroplasty implants and bone graft. But the unwanted screw or driver breakage can be a direct result of excessive driving torque due to the thread cutting resistance. Previous studies showed that bone drill bit cutting rake angle was a critical factor and was inversely related to the bone cutting efficiency. 1, 2, 3, 4. (Figure 1) However to date there was no data for how the rake angle could influence the performance of self tapping bone screw. The purpose of this study was to investigate the torque generated by the self tapping cortical screw in simulated bone insertion as a function of the screw tip cutting flute rake angle. Methods. Two 5 mm thick BM5166 polyurethane block were stacked together and drilled through with 2.5mm diameter holes. Five 30mm long 3.5 mm diameter Ti6AL4V alloy self tapping cortical screws with 0°rake angle cutting flutes (Figure 2) were inserted in the holes and driven by the spanner attached to the test machine (Z5.0TN/TC-A-10) with a displacement control of 3 revolutions/min and 30N constant axial loading. The screws were driven into the stacked polyurethane block for 8mm depth. The maximum driving torque was recorded. Procedure was repeated for five same screws but with 7° rake angle cutting flutes. (Figure 2) The driving torqueses were compared. Student t test was performed with confidence level of 95% was assumed. Results. The average insertion driving torque for the screw with 7° rake angle was 30% less torque required than that of the screw with 0° rake angle. (P=5.3E–06<0.05) (Table 1). Conclusion and discussion. Screw failure during the insertion would be a nightmare. A slight positive rake angle significantly decreases the torque resistance. This design feature can significantly increase the safety margin of the self tapping screw implants and screw driving instruments. The likely mechanism would be the positive rake angle generated a more efficient bone cutting instead of pushing. More study on driving torque as a function of wider rake angle change is warranted. For figures and tables, please contact authors directly

250 words max Long polished cemented femoral stems, such as the Exeter Hip Revision stem, are one option available to the revision hip arthroplasty surgeon. When proximal bone stock is compromised, distal fixation is often relied upon for stability of the femoral component. In such circumstances, torsional forces can result in debonding and loosening. This study compared the torsional behaviour of a cemented polished and featureless (plain) stem with cemented, polished stems featuring fins or flutes. Nine torsional tests were carried out on each of these three different stem designs. The finned stem construct was significantly stiffer than the fluted stem (mean 24.5 Nm/deg v 17.5 Nm/deg). The plain stem mean stiffness was less than the featured stems (13 Nm/deg), but wide variability lead to no statistically significant difference. The maximum torque of the finned (30.5 Nm) and fluted stems (29 Nm) was significantly higher than the plain stem (10.5 Nm); with no significance to the difference between the finned and fluted stems. Distal stem features may provide a more reliable and greater resistance to torque in polished, cemented revision hip stems. Finned stem features may also increase the stiffness of the construct. Consideration should thus be given to the incorporation of distal stem features in the design of revision hip stems

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared the modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In two studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a matched cohort of monoblock cobalt chromium stems. As mentioned one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post-revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction more recently, at our institution we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done through an endofemoral approach. In this the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this system more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution, we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

Summary Statement. Proximal femoral bony deficits present a surgical and biomechanical challenge to implant longevity in revision hip arthroplasty. This work finds comparable primary stability when a distally fixing tapered fluted stem was compared with a conical design in cadaveric tests. Introduction. Proximal bony deficits complicate revision hip surgery and compromise implant survival. Longer distally fixing stems which bypass such defects are therefore required to achieve stability compatible with bony ingrowth and implant longevity. Aims. It is hypothesised that a tapered stem will provide superior rotational stability to a conical design. This work therefore aims to compare the primary stability and biomechanical properties of a new design of tapered fluted modular femoral stem (Redapt®, Smith & Nephew) with that of a conical fluted stem (Restoration®, Stryker). Materials & Methods. 7 Pairs of cadaveric femora were obtained according to strict inclusion/exclusion criteria. Each underwent dual energy x-ray absorptiometry and calibration plain-film radiographs were taken. Digital templating was performed using TraumaCad (Voyant Health, Brainlab) to determine implant sizing. Both stems are fluted, modular and manufactured from titanium. The control stem (Restoration) featured a straight conical design and the investigation stem (Redapt) a straight tapered design. Implantation was performed by a revision arthroplasty surgeon familiar with both systems. Proximal bone deficiency was reproduced using an extended trochanteric osteotomy with removal of metaphyseal bone before reattaching the osteotomy. Primary stability in the axial, sagittal and coronal planes was assessed using micromotion transducers (HBM, Darmstadt, Germany) and also by Radiostereometric Analysis (RSA). RSA employs simultaneous biplanar radiographs to measure relative movement. Two 1mm tantalum beads were mounted on the prosthesis with the centre of the femoral head taken as the third reference point. Beads were placed proximally in the surrounding bone as rigid body markers. Each bone was potted according to the ISO standard for fatigue testing and cyclically loaded at 1Hz for at least 3 increments (750–350N, 1000–350N, 1500–350N) for 1000 cycles. RSA radiographs were taken at baseline and on completion of each cycle. A strain analysis was concurrently performed using a PhotoStress® (Vishay Precision Group, Raleigh, USA) photoelastic coating on the medial femoral cortex. Each bone was loaded intact and then with the prosthesis in-situ at 500N increments until strain fringes were identified. Once testing was completed, the stems were sectioned at the femoral isthmus and data is presented on the cross-sectional fit and fill observed. Results. Both stem designs showed comparable primary stability with all stems achieving clinically acceptable micromotion (<150 μm) when loaded at body weight. A larger proportion of the control stems remained stable as loading increased to x2-3 body weight. Transducer-recorded migration appeared greatest in the axial plane (y axis) with negligible distal movement in the coronal or sagittal planes. Point motion analysis (RSA) indicated most movement to be in the coronal plane (x-axis) whereas segment motion analysis showed rotation about the long axis of the prosthesis to be largest. Photoelastic strain patterns were transferred more distally in both designs, however substantial stress shielding was also observed. Discussion/Conclusion. Both designs achieved adequate distal fixation and primary stability under representative clinical loading conditions. This work supports the continued use of this novel stem design for revision surgery in the presence of extensive proximal bone loss

Introduction. Undersizing of an uncemented femoral stem is a post-operative description of a radiograph with unclear clinical importance. It may not always translate into a suboptimal clinical outcome. Aim. To describe a novel classification system of undersizing in a fully hydroxyapatite coated femoral implant, assess if it could be reliably reported between observers, and describe a simple way to assess the degree of undersizing on an AP radiograph. Methods. A retrospective review of 1000 consecutive total hip arthroplasties was conducted. Two investigators reviewed post-operative radiographs independently for stem undersizing. The data was tested for inter and intra-observer agreement using the Kappa method. Results. Undersizing was classified as:. Varus - Stem in contact proximally with medial calcar, and distally with lateral cortex. Valgus - Stem in contact proximally with lateral cortex, and distally with medial cortex. Uniform - Continuous margin around the stem of at least one-half tip width of the stem throughout. Champagne flute - Distal stem fills the narrow diaphysis with insufficient bony contact at the wide metaphysis. If varus or valgus undersizing was present we described the formation of two triangles of excess cancellous space around the implant, each having overlapping apices signifying undersizing by at least two sizes. 32% of the stems were undersized with Kappa demonstrating very good (89%) to good (86%) inter and intra observer agreement respectively. 50% of undersized stems were uniformly undersized, 36% were varus, 6% valgus, and 8% were in a champagne fluted shaped femur. A higher percentage of the lateralised (KLA) stems were undersized compared to other neck configurations (40%). 54% of these were varus undersized and this increased the offset up to 2cm. Conclusion. We describe a classification system for undersizing in hip arthroplasty. KLA stems have an increased tendency to be undersized in varus, thereby increasing the overall offset

Introduction: The use of self-tapping screws has become increasingly popular since it allows for a rapid screw placement avoiding the tapping step during ORIF of fractures.. While sharing the same basic principle of cutting flutes and partial threads at the tip, at least four types of screw design is currently available, varying in the number and shape of cutting flutes. The purpose of this biomechanical study was to research for any significant difference between the various self-tapping screws. Material and Methods: Three different designs of 4.5-mm self-tapping screws and one standard 4.5 screw serving as control were compared for pull-out strength after insertion into an adult human non-embalmed cadaveric humeri. All specimens were machined to a 5 mm uniform cortical thickness. Four equidistant 3.2 mm holes were drilled into each specimen by an MTS mounted drill. All screws were inserted randomly in one of the four positions using a hand screwdriver. The cortical bone specimen was secured between two metal plates to the base of a MTS machine while a uniaxial tensile force was applied to the jig for screw removal at a rate of 0.833 mm/sec until holding power had decreased to 25 % of the maximum. Load displacement curves were recorded. Resulting data was analyzed using paired student-t tests. P values of less then 0.05 were considered statistically significant. Results: The mean load-to-failure was 97.4167N (S.D. 13.29924) for the Synthes control screw, 69.2333N (S.D. 4.48360) for the Synthes self-tapping screw, 67.15 (S.D. 11.23864) for the Stryker self-tapping screw, and 55.0667 (S.D. 8.59271) for the ODI self-tapping screw. A significant difference was found between the mean pull-out strength of the Synthes control screw when compared to each of the three self-tapping screws (Pairs 1–3, P < 0.05). Furthermore, the mean pull-out strength of the ODI self-tapping screw was found to be significantly less than Stryker self-tapping screw (Pair 6, P < 0.05). There was no significant difference between Synthes self-tapping screws and Stryker self-tapping screws (Pair 5, P < 0.05). Discussion and conclusion: Self tapping screws with three short cutting flutes performed better than those with two long cutting flutes. Despite of the different designs and length of the cutting flutes in self-tapping screws, they all have less pull out strength than regular screws

Cementless stem fixation is a widely used method of stem revision in North America and elsewhere in the world. There is abundant literature in its support. Most of the reports from 1985 to 2005 related to proximally or extensively porocoated designs, the former falling into disfavor with time because of unpredictable outcomes. With few exceptions (e.g. S-ROM) the modularity of these designs was limited to the head/neck junction. But this generation of designs was associated with some issues such as insertional fractures, limited control of anteversion (and risk of dislocation), limited applicability in the setting of severe bone loss (Paprosky Type 4 osteolysis or Vancouver Type B3 periprosthetic fracture), as well as ongoing concern relating to severe proximal stress shielding. In the past decade we have seen the mounting use of a new design concept: tapered fluted titanium stems (TFTS), which incorporate the advantages of titanium (for less flexural rigidity), conical taper (for vertical taper-lock stability), longitudinal ribs or flutes (for rotational stability), and surface preparation which attracts bone ongrowth for long term fixation. Four consecutive reports from our center have documented the superiority of the TFTS in our hands, with encouraging outcomes even when dealing with severe bone loss or periprosthetic fractures. There is an increasing body of other literature which reports a similar experience. Furthermore, with increasing experience and confidence in this design concept, we now use a monoblock or non-modular design in the majority of cases in which a TFTS is indicated. This circumvents the potential drawbacks of stem modularity, including taper corrosion and taper junction fracture. Our recent report of this concept in 104 cases with a 2-year minimum follow-up supports the use of this concept in many if not most stem revisions. The question remains as to which should be favored? Because of equipoise in the outcomes of the two fundamental stem designs, at least in our hands, clearly the surgeon needs to ask other, more practical questions:. Am I familiar enough with the TFTS technique so as to bypass the potential versatility of the modular stem for the simplicity and potential cost savings of the non-modular?. Is this a case in which modularity will offer me distinct advantages (periprosthetic fracture, and severe bone loss as examples). Should I introduce the nonmodular TFTS to my practice, choosing straightforward cases first; ones in which I would comfortably and with confidence use an extensively porocoated stem?