Novel concept of a modular hip implant could contribute to less implant failure in THA: a hypothesis
© The Author(s) 2018
Received: 7 November 2017
Accepted: 26 December 2017
Published: 8 January 2018
The modularity in total hip arthroplasty (THA) allows orthopaedic surgeons for an exact reconstruction of hip biomechanical parameters especially in revision and tumor arthroplasty. Modular structured femoral stems using taper junctions showed increased implant breakage in the recent past.
Presentation of the hypothesis
We hypothesize that a novel modular stem-neck-interface leads to less implant breakage compared to conventional femoral stems.
Testing of the hypothesis
For this purpose, a novel modular femoral stem for THA was to design and manufacture. Therefore, three different variants of interface mechanisms were developed that enable a simple connection between the stem and the neck modules and allow for intra-operatively adjustment. Three prototypes A, B and C were manufactured and subsequently dynamic fatigue (ISO 7206–6) and body donor tested.
Implication of the hypothesis
Modularity in THA is mainly applied in THA as well as in revision and tumor arthroplasty. Modular implants are barely used because of the high risk of breakage. Another risks in this context are taper fretting, corrosion and disconnection. With the novel design, it should be possible to detach the stem and neck module intra-operatively to adapt the anatomical situation. The novel coupling mechanism of the rotating interface seems to be the most suitable for a secure stem-neck connection and is characterized by good intraoperative handling.
The most important treatment goal in total hip arthroplasty (THA) is the recovery of normal function. Key requirements for this goal include the permanent and secure anchoring of the implants used and an exact biomechanical reconstruction of patient anatomy. Some hip biomechanical parameters need to be adjusted according to the individual situation intra-operatively. These includes the position of the prosthetic femoral head centre in relation to the femoral bone as well as the position of the prosthetic acetabular cup centre in the pelvic bone. The immediate consequence of malpositioning is a leg length discrepancy, in the majority of cases an increase in leg length, noticeable by patient and requiring orthopaedic treatment .
Also relevant are changes to femoral offset. Offset reduction reduces the lever arm of the hip muscles and thus reduces their force. Both increases in leg length and offset reduction can be sensed by patients, reduces mobility and require permanent post-operative orthopaedic compensation (e.g. shoe elevation). Further treatment is often required, yet does not always lead to full compensation, often leaving patient’s with a limp or a Trendelenburg gait. Excessive changes in the biomechanics pose further risks, including e.g. dislocations, implant loosening, breakage and wear, potentially inducing wear-associated osteolysis [2, 3]. All these mentioned factors can lead to drastic cost increases due to new medication needs, physiotherapy and further orthopaedic treatment. To avoid such situations, the biomechanical aspects of the operation need to be looked at precisely during the operation.
One approach for the reconstruction of the original anatomical situation and biomechanics in primary THA is the deployment of a modular structure of the femoral stem. There are different solutions available such as the Metha-Stem of Aesculap (Aesculap, Tuttlingen, Germany) or the Oval-Stem of Zimmer (Zimmer, Warsaw, USA). Both approaches showed increased implant breakage and did not lead to the success hoped for [4–14]. One reason for this is the use of taper junctions between the stem and neck modules. The problem is that positioning the coupling module within the femoral medullary space requires a very fine implant design. The combination of taper interface and the long lever lead to a high peak strain that increases the risk of breakage in both components. The taper junction is also not able to absorb horizontal forces. In addition, this kind of connection is difficult to disassemble intra-operatively in order to adjust it.
Presentation of the hypothesis
We hypothesize that a novel design of modular stem-neck-interface leads to less implant breakage compared to conventional femoral stems using taper connections. Furthermore, a simple intra-operatively handling for the surgeon should be ensured, which would help to select components with the ideal geometry to reconstruct the original hip architecture.
Testing of the hypothesis
Using computer aided design (CAD), three different variants (A, B, C) of novel connection mechanisms were developed that enable a simple connection between the stem and the neck modules and allow for detachment and precise biomechanical adjustment intra-operatively.
Variant A: Sliding interface (conical dovetail)
Variant B: Rotatable interface (screw thread principle)
The head neck module is positioned at a 90° tilt onto the stem-module and centred above by means of a bolt. The neck module rotates around the central bolt, pulling towards the stem module via the screw thread and finally tightening against the larger flat surface. The system is stabilized with pegs, inserted during the operation (e.g. high-strength synthetic pegs). The interface itself serves as the collar of the prosthesis due to its protruding design (Fig. 1).
Variant C: Sliding interface (double-lapped dovetail)
The neck module is slid onto the stem module linearly. The interface is produced by a linear double-lapped dovetail. The system is sealed by means of a cap with a conical position and a self-locking sleeved screw through the interface. This interface variant can be made with and without a collar (Fig. 1).
Manufacturing the prototypes
Dynamic fatigue limit testing
Variant A - conical dovetail
Variant B - rotating interface
After fatigue testing, no damage could be seen (Fig. 4). The loosening torque of the self-lock screw connection M5 consisted of 20–25% of the tightening torque. At rest, the loosening torque was 90% of the tightening torque. This is not necessarily related to loosening of the screw connection. As a consequence of dynamic strain, the rotating interface was ‘overwound’, which lowers the preload on the screw connection. This overwinding of 3° at the end of the experiment was clear and permanent.
Variant C - double-lapped dovetail
The horizontal crack occurred above the modular connection (Fig. 4). The loosening torque of the metric screw connection M3 was similar to the tightening torque. As a consequence of deformation and loosening of the connection, the preload was increased on the sealing cap due to the conical construction, without overloading the cap. This led to a perpendicular clamping effect on the screw connection.
Implication of the hypothesis
Until now, modularity in THA is mainly applied in revision and tumor arthroplasty [15–18]. In primary THA modular implants are barely used because of the high risk of breakage [11, 19–21]. Another risks in this context are taper fretting, corrosion and disconnection which were observed [10, 12, 19, 22–25]. In contrast, some authors performed a simulation with in vivo conditions and recognized no corrosion increase at the interface . Further, in primary THA the application of taper junction for connecting the implant modules leads due to the arrangement inside the femur to a filigree design (e.g. cone 10/12 mm) and unfavorable leverage ratios with peak loads in the medial force application. This results in high breakage rates in the case of the Metha-Stem or in the case of the oval handle [5–14]. In contrast for modular tumor endoprosthesis partially much larger taper connections can be applied (e.g. 16/18 mm). In this regard, a number of complications such as disconnections are reported, but no relevant breakage rates .
In the present hypothesis study, we introduced a new concept for a modular THA implant. With the novel interface design, it should be possible to detach the stem and neck module intra-operatively to adapt the anatomical situation. The use of a modular stem implant in primary arthroplasty would disconnect the neck in case of THA revision for a less invasive access to the cup or insert. Therefor the stem module remains in the femur during adjustment. New geometries for the neck module should be offered to the surgeon in order to adjust hip biomechanic parameters like leg length, femoral offset as well as the femoral anteversion [11–14] more flexible and precisely. The coupling mechanism of the rotating interface seems to be the most suitable for a secure connection. However, these findings are based on one sample of each coupling mechanism and do not represent a statistically verified test result. Thus, further development is necessary to optimize this coupling interface. This includes strengthening the wall-thickness to further decrease fracturing and increasing the notch radius at the interface to prevent cracking. Furthermore, increasing processing precision and increasing tightening torque for the rotating interface is required to prevent overwinding that could decrease preload.
A newly designed femoral component, consisting of stem and neck module, was introduced. The main focus was on a better adaptability for the intraoperatively adjustment of biomechanical hip parameters e.g. the leg length as well as an increased resistance to implant breakage. With the novel design, it should be possible to adapt the anatomical architecture by using different combinations of stem and neck modules.
Variant B with the coupling mechanism of the rotating interface seems to be the most suitable for a secure connection when looking at the results of fatigue testing and intra-operatively handling. It will be examined for further testing, design guidance, simulation control and construction revisions. Thus, the results of this hypothesis study is intended as a basis for discussion for a novel thought to the development of hip replacements.
The authors would like to thank Michael Schmidt for providing the figures included in this manuscript.
The research project KF2039721AK2 was funded by the AiF within the Central Innovation Programme for SMEs (ZIM) by the Federal Ministry of Economics and Technology (BMWi) following an Order by the German Federal Parliament.
Availability of data and materials
RG is the primary author and participated in all aspects of this study. SS, RM, MK and CR designed and manufactured the technical components. NH and TP gave clinical input from the perspective of orthopedic surgeon. WGD and TP supervised the study. All authors read and approved the final manuscript.
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Consent for publication
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- Renkawitz T, Weber T, Dullien S, Woerner M, Dendorfer S, et al. Leg length and offset differences above 5mm after total hip arthroplasty are associated with altered gait kinematics. Gait Posture. 2016;49:196–201.View ArticlePubMedGoogle Scholar
- Greenfield EM, Bechtold J. What other biologic and mechanical factors might contribute to osteolysis. J Am Acad Orthop Surg. 2008;16(1 Suppl):56–62.View ArticleGoogle Scholar
- Kretzer JP, Jakubowitz E, Krachler M, Thomsen M, Heisel C. Metal release and corrosion effects of modular neck total hip arthroplasty. Int Orthop. 2009;33(6):1531–6.View ArticlePubMedPubMed CentralGoogle Scholar
- Kohler S, Ratayski H, Zacher J. Implantatbedingte Brüche des Schenkelhals-Konusadapters einer modularen Kurzschaft-Hüftendoprothese – Patientenmanagement und OP-Technik. Z Orthop Unfall. 2011;149(02):185–90.View ArticlePubMedGoogle Scholar
- Goldberg JR, Gilbert JL, Jacobs JJ, Bauer TW, Paprosky W, et al. A multicenter retrieval study of the taper interfaces of modular hip prostheses. Clin Orthop Relat Res. 2002;401:149–61.View ArticleGoogle Scholar
- Chu Y, Elias JJ, Duda GN, Frassica FJ, Chao EY. Stress and micromotion in the taper lock joint of a modular segmental bone replacement prosthesis. J Biomech. 2000;33(9):1175–9.View ArticlePubMedGoogle Scholar
- Hinrichs F, Boudriot U, Hunerkopf M, Griss P. Design and first clinical results with the ZMR taper revision prosthesis. Z Orthop Grenzgeb. 2005;143(3):355–9.View ArticleGoogle Scholar
- Buttaro MA, Mayor MB, van Citters D, Piccaluga F. Fatigue fracture of a proximally modular, distally tapered fluted implant with diaphyseal fixation. J Arthroplast. 2007;22(5):780–3.View ArticleGoogle Scholar
- Siegmeth A, Garbuz DS, Masri BA. Salvage procedures and implant selection for periprosthetic femoral fractures. Injury. 2007;38(6):698–703.View ArticlePubMedGoogle Scholar
- Kop AM, Swarts E. Corrosion of a hip stem with a modular neck taper junction: a retrieval study of 16 cases. J Arthroplast. 2009;24(7):1019–23.View ArticleGoogle Scholar
- Skendzel JG, Blaha JD, Urquhart AG. Total hip arthroplasty modular neck failure. J Arthroplast. 2011;26(2):338.e1–4.View ArticleGoogle Scholar
- Barrack RL, Burke DW, Cook SD, Skinner HB, Harris WH. Complications related to modularity of total hip components. J Bone Joint Surg. 1993;75(5):688–92.Google Scholar
- Chmell MJ, Rispler D, Poss R. The impact of modularity in total hip arthroplasty. Clin Orthop Relat Res. 1995;319:77–84.Google Scholar
- Jones RE. Modular revision stems in total hip arthroplasty. Clin Orthop Relat Res. 2004;420:142–7.View ArticleGoogle Scholar
- Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur. J Bone Joint Surg. 1994;76(2):178–86.Google Scholar
- von Salis-Soglio G, Ghanem M, Meinecke I, Ellenrieder M, Klinger H-M, et al. The modular endoprosthetic system Munich-Luebeck (MML): potential applications and results in the lower extremities. Orthopade. 2010;39(10):960–7.View ArticleGoogle Scholar
- Gebert C, Wessling M, Gotze C, Gosheger G, Hardes J. The Modular Universal Tumour And Revision System (MUTARS(R)) in endoprosthetic revision surgery. Int Orthop. 2010;34(8):1261–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Schmolders J, Koob S, Schepers P, Gravius S, Wirtz DC, et al. The role of a modular universal tumour and revision system (MUTARS(R)) in lower limb Endoprosthetic revision surgery - outcome analysis of 25 patients. Z Orthop Unfall. 2017;155(1):61–6.PubMedGoogle Scholar
- Dangles CJ, Altstetter CJ. Failure of the modular neck in a total hip arthroplasty. J Arthroplast. 2010;25(7):1169.e5–7.View ArticleGoogle Scholar
- Wright G, Sporer S, Urban R, Jacobs J. Fracture of a modular femoral neck after total hip arthroplasty: a case report. J Bone Joint Surg Am. 2010;92(6):1518–21.View ArticlePubMedPubMed CentralGoogle Scholar
- Sotereanos NG, Sauber TJ, Tupis TT. Modular femoral neck fracture after primary total hip arthroplasty. J Arthroplast. 2013;28(1):196.e7–9.View ArticleGoogle Scholar
- Bobyn JD, Tanzer M, Krygier JJ, Dujovne AR, Brooks CE. Concerns with modularity in total hip arthroplasty. Clin Orthop Relat Res. 1994;298:27–36.Google Scholar
- Collier JP, Surprenant VA, Jensen RE, Mayor MB, Surprenant HP. Corrosion between the components of modular femoral hip prostheses. J Bone Joint Surg. 1992;74(4):511–7.Google Scholar
- Grupp TM, Weik T, Bloemer W, Knaebel H-P. Modular titanium alloy neck adapter failures in hip replacement--failure mode analysis and influence of implant material. BMC Musculoskelet Disord. 2010;11:3.View ArticlePubMedPubMed CentralGoogle Scholar
- Ellman MB, Levine BR. Fracture of the modular femoral neck component in total hip arthroplasty. J Arthroplast. 2013;28(1):196.e1–5.View ArticleGoogle Scholar