This study compared the pullout forces of the initial implantation and the “cement-in-cement” revision technique for short and standard-length (125 mm vs. 150 mm) Exeter® V40 femoral stems used in total hip arthroplasty (THA). The idea that the pullout force for a double taper slip stem is relative to the force applied to the femur and that “cement-in-cement” revision provides the same reproduction of force. A total sample size of 15 femoral stems were tested (Short, n = 6 and Standard, n = 9). 3D printed fixtures for repeatable sample preparation were used to minimize variance during testing. To promote stem subsidence and to simulate an in vivo environment, the samples were placed in an incubator at 37°C at 100% humidity and experienced a constant compressive loading of 1335 N for 14 days. The samples underwent a displacement-controlled pullout test. After the initial pullout test, “cement-in-cement” revision will be performed and tested similar to the initial implantation to observe the efficacy of the revision technique. To compare the pullout forces between the two groups, a Kruskal-Wallis test using a significance level of 0.05 was conducted. The mean maximum pullout force for the short and standard-length femoral stems were 3939 ± 1178 N and 5078 ± 1168 N, respectively. The Kruskal-Wallis test determined no statistically significant difference between the two groups for the initial implantation (p = 0.13). The “cement-in-cement” revision pullout force will be conducted in future testing. This study demonstrated the potential use of short stem designs for THA as it provides similar levels of fixation as the standard-length femoral stem. The potential benefits for using a short stem design would be providing similar load transfer to the proximal femur, preserving proximal metaphyseal femoral bone in primary replacement, and reducing the invasiveness during revision.
Reverse shoulder arthroplasty (RSA) is commonly used to treat patients with rotator cuff tear arthropathy. Loosening of the glenoid component remains one of the principal modes of failure and is the main complication leading to revision. For optimal RSA implant osseointegration to occur, the micromotion between the baseplate and the bone must not exceed a threshold of 150 µm. Excess micromotion contributes to glenoid loosening. This study assessed the effects of various factors on glenoid baseplate micromotion for primary fixation of RSA. A half-fractional factorial experiment design (2k-1) was used to assess four factors: central element type (central peg or screw), central element cortical engagement according to length (13.5 or 23.5 mm), anterior-posterior (A-P) peripheral screw type (nonlocking or locking), and bone surrogate density (10 or 25 pounds per cubic foot [pcf]). This created eight unique conditions, each repeated five times for 40 total runs. Glenoid baseplates were implanted into high- or low-density Sawbones™ rigid polyurethane (PU) foam blocks and cyclically loaded at 60 degrees for 1000 cycles (500 N compressive force range) using a custom designed loading apparatus. Micromotion at the four peripheral screw positions was recorded using linear variable displacement transducers (LVDTs). Maximum micromotion was quantified as the displacement range at the implant-PU interface, averaged over the last 10 cycles of loading. Baseplates with short central elements that lacked cortical bone engagement generated 373% greater maximum micromotion at all peripheral screw positions compared to those with long central elements (p < 0.001). Central peg fixation generated 360% greater maximum micromotion than central screw fixation (p < 0.001). No significant effects were observed when varying A-P peripheral screw type or bone surrogate density. There were significant interactions between central element length and type (p < 0.001). An interaction existed between central element type and level of cortical engagement. A central screw and a long central element that engaged cortical bone reduced RSA baseplate micromotion. These findings serve to inform surgical decision-making regarding baseplate fixation elements to minimize the risk of glenoid loosening and thus, the need for revision surgery.
During the last few years there has been renewed interest in hip resurfacing. The advantages of such prostheses include minimal bone resection and more physiological loading of the proximal femur. The purpose of this study was to investigate the stress distribution to the upper femur following a metal-on-metal hip resurfacing and the influence of a short stem on femoral bone loading. An accurate and validated finite element (FE) model of the proximal femur was utilised. This was created from CT data of cadaveric femurs. The validation process included weighing, modal analysis, strain gauging and ultrasound material testing of the bone. The maximum elastic modulus in the principal direction was 22.9ÊGPa. The elastic moduli of the cement and implant were 1.8 and 200 GPa respectively. The joint force and 4 muscle loads were applied accordingly and adapted to the specific geometry of the bone. The load case represented the 45% position in the gait cycle, corresponding to toe-off. The hip joint force of 2.2kN, approximately 30° superior to the pole of the implant, was applied as a pressure distribution over a 60° spherical segment, modelling the large contact area of the metal-on-metal articulation. Various scenarios with and without an implant were compared. The distribution of the von Mises stresses in the normal femur without an implant reflected the distribution of the bone’s mechanical properties: the joint load was transferred from the superior surface of the femoral head, through its centre to the dense cortical bone of the calcar and diaphysis. The presence of the resurfacing prosthesis did not significantly affect the stress distribution in the proximal femur, except for a reduction of stresses in the superior region of the femoral head. Varying the length of the stem and its fixation did not significantly affect this stress distribution. A resurfacing prosthesis without a stem resulted in more normal stresses in the superior region of the femoral head. Compared to the normal femur without an implant the FE analysis of the resurfacing prosthesis demonstrated stress shielding in the superior region of the femoral head. This stress shielding was reduced when a resurfacing component without a stem was used. This advantage must be weighed against the disadvantage that without a stem it is more difficult to accurately position the implant and achieve a uniform cement mantle.
