A Calcar Collar Is Protective Against Early Torsional/Spiral Periprosthetic Femoral Fracture

Abstract

Background: Periprosthetic fracture is a leading reason for readmission following total hip arthroplasty. Most of these fractures occur during the early postoperative period before bone ingrowth. Before ingrowth occurs, the femoral component can rotate relative to the femoral canal, causing a spiral fracture pattern. We sought to evaluate, in a paired cadaver model, whether the torsional load to fracture was higher in collared stems. The hypothesis was that collared stems have greater load to fracture under axial and torsional loads compared with collarless stems. Methods: Twenty-two cadaveric femora (11 matched pairs) with a mean age of 77 ± 10.2 years (range, 54 to 90 years) were harvested. Following dissection, the femora were evaluated with use of a dual x-ray absorptiometry scanner and T scores were recorded. We utilized a common stem that is available with the same intraosseous geometry with and without a collar. For each pair, 1 femur was implanted with a collared stem and the contralateral femur was implanted with a collarless stem with use of a standard broaching technique. A compressive 68-kg load was applied to simulate body weight during ambulation. A rotational displacement was then applied until fracture occurred. Peak torque prior to fracture was measured with use of a torque meter load cell and data acquisition software. Results: The median torque to fracture was 65.4 Nm for collared stems and 43.1 Nm for uncollared stems (p = 0.0014, Wilcoxon signed-rank test). The median T score was –1.95 (range, –4.1 to –0.15). The median difference in torque to fracture was 29.18 Nm. As expected in each case, the mode of failure was a spiral fracture around the implant. Conclusions: Collared stems seemed to offer a protective effect in torsional loading in this biomechanical model comparing matched femora. Clinical Relevance: These results may translate into a protective effect against early periprosthetic Vancouver B2 femoral fractures that occur before osseous integration has occurred.

The Impact of Prior Fragility Fractures on Complications After Total Hip Arthroplasty: A Propensity Score–Matched Cohort Study

“…Surgeons make decisions during THA regarding hip stem geometry and method of fixation such that understanding the risk profile of each patient is paramount. In patients undergoing THA with Dorr type C bone or increased risk of fracture, surgeons may choose press-fit femoral stem geometries that have increased stability to rotational and axial forces [22]. In patients with severely compromised bone and risk factors, cemented stems or prophylactic cerclage wires may be indicated [23].…”

Survival and performance of a dual tapered-wedge fully HA-coated press fit femoral stem

“…Demey et al reported that collared un-cemented stems have significantly greater immediate stability than collarless as they are able to withstand greater vertical and horizontal forces before the initiation of subsidence and subsequent fracture [30]. Another recent biomechanical analysis suggests that collared stems may offer a protective effect in torsional loading which translates to reduced risk of early peri-prosthetic fractures [31]. Second, all of our stems that sustained subsidence greater than 4 mm were found to have Dorr B and Dorr C type femur morphology.…”

Similar stress repartition for a standard uncemented collared femoral stem versus a shortened collared femoral stem

“…Calcar resorption or osteolysis has been described with the use of collared stems previously [24,25]. However, countering this are several studies that have reported less stem subsidence and early periprosthetic fracture with the use of a collared prosthesis [26][27][28]. The advantages of a collar with a shortened stem have not been assessed in the literature.…”