Failure of Cementless Fixation of the Femoral Component in Total Hip Arthroplasty

Abstract

The basic concepts involved in cementless fixation of the total hip arthroplasty femoral component have been controversial. Some clinicians advocate fixation only of the proximal portion of the stem so that weight-bearing loads will be transferred proximally, and proximal stress shielding will be avoided. Others advocate distal fixation to ensure rigidity of fixation but concede that it will lead to proximal stress shielding and bone loss. However, clinical evidence suggests that the design of the implant is one important factor in determining stress shielding. When the stem is smooth and cylindrical distally, proximal stress relief does not occur, even when the stem is fixed tightly distally. Because femoral component loosening is the most common clinical problem with cementless total hip arthroplasty, every effort should be made to achieve fixation of the implant. Proximal and distal fixation can be achieved with most of the available implants. For tight proximal fixation, a good proximal implant design and a precise line-to-line preparation technique are critical, but aggressive broaching and interference-fit techniques result in a high rate of proximal femoral fracture during preparation and implantation. When the conditions are good for excellent proximal fixation, a flexible stem should be selected to apply a large amount of stress proximally. The stress transferred through distal fixation will be small in this situation, and the reaming technique of the femoral diaphysis does not need to be very aggressive. Approximately 10 to 20 mm of tight distal fit combined with the 0.5-mm underreaming technique provides sufficient distal fixation, and the chance of distal femoral fracture during insertion of the stem is minimum with this technique. When conditions are unfavorable for excellent proximal fixation, such as in revision hip arthroplasty, or when a proximal deformity or osteoporosis is present, a relatively rigid stem should be selected to avoid overloading proximal fixation and, thus, generating large proximal micromotion. The stress transferred through distal fixation will be large in this situation, and a relatively aggressive but well-controlled reaming technique of the diaphysis is required. Approximately 20 to 40 mm of tight distal fit combined with a 0.5-mm underreaming technique is adequate to obtain sufficient distal fixation and still avoid distal femoral fracture. Implant design features that improve proximal fixation and instrumentation features that improve bone preparation and decrease the risk of failure will broaden the indications for cementless fixation. As fixation and instrumentation improve, more flexible implants can be developed to improve bone preservation and avoid proximal stress relief.(ABSTRACT TRUNCATED AT 400 WORDS)