Can We Predict Fracture When Using a Short Cementless Femoral Stem in the Anterior Approach?

• Published in: The Journal of arthroplasty Vol. 37; no. 8; pp. S901 - S907
• Main Authors: McGoldrick, Niall P., Cochran, Michael J., Biniam, Brook, Bhullar, Raman S., Beaulé, Paul E., Kim, Paul R., Gofton, Wade T., Grammatopoulos, George
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-08-2022
• Subjects: anterior approach; arthroplasty; fracture; periprosthetic; short stem; short stem; anterior approach; arthroplasty; periprosthetic; fracture
• ISSN: 0883-5403; 1532-8406
• DOI: 10.1016/j.arth.2022.03.054

Short cementless femoral stems may allow for easier insertion with less dissection. The use of short stems with the anterior approach (AA) may be associated with a considerable perioperative fracture risk. Our aim was to evaluate whether patient-specific femoral and pelvic morphology and surgical technique, influence the perioperative fracture risk. Furthermore, we sought to describe important anatomical thresholds alerting surgeons.
A single-center, multi-surgeon retrospective, case-control matched study was performed. Thirty nine periprosthetic fractures (3.4%) in 1,145 primary AA THAs using short cementless stems were identified. These were matched with 78 THA nonfracture controls for factors known to increase the fracture risk. A radiographic analysis using validated software measured femoral (canal flare index [CFI], morphological cortical index [MCI], and calcar-calcar ratio [CCR]) and pelvic (Ilium-ischial ratio [IIR], ilium overhang, and anterior superior iliac spine [ASIS] to greater trochanter distance) morphologies and surgical techniques (% canal fill). A multivariate and Receiver-Operator Curve (ROC) analysis was used to identify fracture predictors.
CFI (3.7 ± 0.6 vs 2.9 ± 0.4, P < .001) and CCR (0.5 ± 0.1 vs 0.4 ± 0.1, P = .006) differed. The mean IIR was higher in fracture cases (3.3 ± 0.6 vs 3.0 ± 0.5, P < .001). Percent canal fill was reduced in fracture cases (82.8 ± 7.6 vs 86.7 ± 6.8, P = .007). Multivariate and ROC analyses revealed a threshold CFI of 3.17 which was predictive of fracture (sensitivity: 84.6%/specificity: 75.6%). The fracture risk was 29 times higher when patients had CFI >3.17 and II ratio >3 (OR: 29.2 95% CI: 9.5-89.9, P < .001).
Patient-specific anatomical parameters are important predictors of a fracture-risk. A careful radiographic analysis would help identify those at a risk of early fracture using short stems, and alternative stem options should be considered.