The impact of polyethylene abrasion on the occurrence of periprosthetic proximal femoral fractures in patients with total hip arthroplasty
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In addition to abrasion-induced osteolysis and ensuing instabilities, the polyethylene (PE) abrasion of total hip arthroplasty (THA) inlays can also cause gait instability due to the decentralization of the hip joint. The current literature yields, as yet, insufficient findings whether these two factors are linked directly or indirectly to a higher risk for periprosthetic proximal femoral fractures (PPFF). The aim of our retrospective evaluation is to analyse the impact of PE abrasion on the pathology of PPFF in patients with THA.
Material and methods
The retrospective evaluation comprises all PPFF in patients with THA in the period from 01/2010 up to 12/2016. The study group (SG) included 66 cases (n = 66). The control group (CG) was comprised of patients with asymptomatic THA (n = 66), who were treated by our outpatient department including routine check-ups and X-ray examinations. We used the matched-pair methodology to scale the period of postsurgical care of the CG to the lifetime of the implant up to PPFF in the SG. We included epidemiologic data, radiological femoral head decentralization, osteolysis (Gruen classification), instabilities, acetabular cup position, and implant properties in our analysis. For the SG, we also included intra-operative signs of abrasion.
The SG showed significantly higher numbers of decentralized THA as signs of inlay erosion with 73% compared to only 41% in the CG (p > 0.001). The SG showed 1 ± 0.68 mm hip joint decentralization as to 0.5 ± 0.59 mm in the CG (p = 0.004). We found significantly more cases of osteolysis in the SG (n = 25) than in the CG (n = 13) (p = 0.003). We found no notable differences in acetabular cup inclination or anteversion as well as cup size. However, differences were significant in femoral head size (SG 32 ± 2.3 mm, CG 36 ± 2.4 mm; p = 0.042) and head material. We found more widespread use of metal femoral heads in the SG than in the CG (SG 1:1, CG 1:21; p = 0.001).
PPFF patients showed significantly higher rates of inlay erosion, resulting in femoral head decentralization and osteolysis. The higher rate of fracture is likely caused by the increasing instability of the implant fixation due to abrasion-induced osteolysis and the associated degradation of bone quality. It is conceivable that the abrasion and decentralization of the THA can also lead to gait instability, and thus, a higher proneness to falls. Gait instability can also be aggravated by increased granulation tissue and effusion due to the inlay abrasion. Although this cannot be substantiated by the investigation. In patients with decentralization of the THA and osteolysis, a radiological follow-up should be performed, and in case of gait instability (femoral head and) inlay replacements should be considered.
KeywordsPolyethylene abrasion Periprosthetic proximal femoral fractures Total hip arthroplasty THA
We acknowledge the support of the German Research Foundation (DFG) and the University Hospital Leipzig within the program of Open Access Publishing.
DZ analyzed and interpreted all patient data and was a major contributor in writing the manuscript. NL and CP carried out the data collection and contributed significantly to the preparation of the manuscript. ME and RM were responsible for the translation and have jointly performed the statistical analyzes. DZ, JKMF, HB, CJ and AR were mainly responsible for the patient treatment and contributed as assistants to the preparation of the work. All authors read and approved the final manuscript.
This study was funded by the non-profit German Research Foundation (DFG) and the University Hospital Leipzig within the program of Open Access Publishing. The funding body had no impact on the design of the study, collection, analysis and interpretation of data as well as writing the manuscript.
Compliance with ethical standards
Conflict of interests
The authors declare no competing interests.
The ethics committee of the University Hospital Leipzig in Germany granted ethical approval (ref. no. 044/14032016). The committee is listed in the Institutional Review Board (IRB) of the Office for Human Research Protections (OHRP) IORG0001320, IRB00001750.
Before the beginning of the study all patients were informed and gave their written consent to treatment contract, the study as well as to the publication of their anonymised data.
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