Thigh pain following a well-fixed total hip arthroplasty (THA) remains problematic and a source of patient dissatisfaction. The purpose of this study is to evaluate if the development of distal femoral cortical hypertrophy (DFCH) is associated with postoperative thigh pain after THA.
Methods:
All patients who underwent an uncomplicated primary THA via a direct anterior approach with the Taperloc Microplasty (Zimmer Biomet, Warsaw, IN, USA) implant between 2011 and 2015 were mailed a pain drawing questionnaire. Radiographs were reviewed at 1 year minimum to determine cortical thickness change from immediate post-op. Thigh pain was compared to DFCH. 293 patients were included in the study.
Results:
Mean follow-up was 3.2 years. A total of 218 hips (74%) had cortical hypertrophy in Gruen zone 3 and 165 hips (56%) had cortical hypertrophy in Gruen zone 5. 52 hips (18%) had ⩾25% cortical hypertrophy in zone 3 and 91 hips (31%) had ⩾25% cortical hypertrophy in zone 5. A total of 44 patients (15%) reported anterior thigh pain and 43 patients (15%) reported lateral thigh pain. Development of DFCH in either Gruen zone 3 or 5 was not associated with anterior or lateral thigh pain. Stem size was positively correlated with zone 3 hypertrophy and inversely related to zone 5 hypertrophy. Thigh pain was not associated with patient age, gender, activity level or stem size.
Conclusions:
The development of distal femoral cortical hypertrophy after THA with a short stem implant was high, but not associated with patient-reported anterior or lateral thigh pain.
LearmonthIDYoungCRorabeckC.The operation of the century: total hip replacement. Lancet2007; 370: 1508–1519.
2.
MaloneyWJHarrisWH.Comparison of a hybrid with an uncemented total hip replacement. A retrospective matched-pair study. J Bone Joint Surg Am1990; 72: 1349–1352.
3.
RitterMACampbellED. Direct comparison between bilaterally implanted cemented and uncemented total hip replacements in six patients. Clin Orthop Relat Res1986; 207: 77–82.
4.
BarrackRLPaproskyWButlerRA, et al. Patients’ perception of pain after total hip arthroplasty. J Arthroplasty2000; 15: 590–596.
5.
BarrackRLRuhELBerendME, et al. Do young, active patients perceive advantages after surface replacement compared to cementless total hip arthroplasty?Clin Orthop Relat Res2013; 471: 3803–3813.
6.
BourneRBRorabeckCHGhazalME, et al. Pain in the thigh following total hip replacement with a porous-coated anatomic prosthesis for osteoarthrosis. A five-year follow-up study. J Bone Joint Surg Am1994; 76: 1464–1470.
7.
JoWLLeeYKHaYC, et al. Frequency, developing time, intensity, duration, and functional score of thigh pain after cementless total hip arthroplasty. J Arthroplasty2016; 31: 1279–1282.
8.
KatsimihasMKatsimihasGLeeMB, et al. Distal femoral cortical hypertrophy: predisposing factors and their effect on clinical outcome. Hip Int2006; 16: 18–22.
9.
ChoYJChunYSRhyuKH, et al. Distal femoral cortical hypertrophy after hip arthroplasty using a cementless doubletapered femoral stem. J Orthop Surg (Hong Kong)2016; 24: 317–322.
10.
DorrLDSmithC.Clinical results from the calcitite-coated press fit APR hip system. Dent Clin North Am1992; 36: 239–246.
11.
HavelinLIEspehaugBVollsetSE, et al. Early failures among 14,009 cemented and 1,326 uncemented prostheses for primary coxarthrosis. The Norwegian Arthroplasty Register, 1987-1992. Acta Orthop Scand1994; 65: 1–6.
12.
EnghCAMassinPSuthersKE.Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res1990; 257: 107–128.
13.
MacDonaldSJRosenzweigSGuerinJS, et al. Proximally versus fully porous-coated femoral stems: a multicenter randomized trial. Clin Orthop Relat Res2010; 468: 424–432.
14.
NamDNunleyRMSauberTJ, et al. Incidence and location of pain in young, active patients following hip arthroplasty. J Arthroplasty2015; 30: 1971–1975.
15.
PetrouGGavrasMDiamantopoulosA, et al. Uncemented total hip replacements and thigh pain. Arch Orthop Trauma Surg1994; 113: 322–326.
16.
HeadWCBaukDJEmersonRHJr.Titanium as the material of choice for cementless femoral components in total hip arthroplasty. Clin Orthop Relat Res1995; 311: 85–90.
17.
NambaRSKeyakJHKimAS, et al. Cementless implant composition and femoral stress: a finite element analysis. Clin Orthop Relat Res1998; 347: 261–267.
18.
LaineHJPuolakkaTJMoilanenT, et al. The effects of cementless femoral stem shape and proximal surface texture on ‘fit-and-fill’ characteristics and on bone remodeling. Int Orthop2000; 24: 184–190.
19.
EnghCABobynJDGlassmanAH.Porous-coated hip replacement. The factors governing bone ingrowth, stress shielding, and clinical results. J Bone Joint Surg Br1987; 69: 45–55.
20.
EnghCABobynJD.The influence of stem size and extent of porous coating on femoral bone resorption after primary cementless hip arthroplasty. Clin Orthop Relat Res1988; 231: 7–28.
21.
KoyanoGJinnoTKogaD, et al. Comparison of bone remodeling between an anatomic short stem and a straight stem in 1-stage bilateral total hip arthroplasty. J Arthroplasty2017; 32: 594–600.
22.
BurchardRBraasSSoostC, et al. Bone preserving level of osteotomy in short-stem total hip arthroplasty does not influence stress shielding dimensions - a comparing finite elements analysis. BMC Musculoskelet Disord2017; 18: 343.
23.
MorreyBFAdamsRAKesslerM.A conservative femoral replacement for total hip arthroplasty. A prospective study. J Bone Joint Surg Br2000; 82: 952–958.
24.
ChenHHMorreyBFAnKN, et al. Bone remodeling characteristics of a short-stemmed total hip replacement. J Arthroplasty2009; 24: 945–950.
25.
MouttetAPhilippotRFarizonF, et al. Five-year follow-up of a hydroxyapatite coated stem. Rev Chir Orthop Reparatrice Appar Mot2008; 94: 746–752.
26.
GoshulakPSamiezadehSAzizMS, et al. The biomechanical effect of anteversion and modular neck offset on stress shielding for short-stem versus conventional long-stem hip implants. Med Eng Phys2016; 38: 232–240.
27.
WolffJ.The law of transformation of the bone. Institut, Charité - Universitätsmedizin Berlin, Hirschwald, 1892.
28.
Van RietbergenBHuiskesRWeinansH, et al. ESB research award 1992. The mechanism of bone remodeling and resorption around press- fitted THA stems. J Biomech1992; 26: 369–382.
29.
ThalmannCHorn LangTBereiterH, et al. An excellent 5-year survival rate despite a high incidence of distal femoral cortical hypertrophy in a short hip stem. Hip Int. Epub ahead of print 22 April 2019. DOI: 10.1177/1120700019834336.
30.
BurkartBCBourneRBRorabeckCH, et al. Thigh pain in cementless total hip arthroplasty. A comparison of two systems at 2 years’ follow-up. Orthop Clin North Am1993; 24: 645–653.
31.
WhitesideLA.The effect of stem fit on bone hypertrophy and pain relief in cementless total hip arthroplasty. Clin Orthop Relat Res1989; 247: 138–147.
32.
GruenTAMcNeiceGMAmstutzHC.“Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res1979; 141: 17–27.
33.
PatelRMLoWMCayoMA, et al. Stable, dependable fixation of short-stem femoral implants at 5 years. Orthopedics2013; 36: e301–e307.
34.
MaierMWStreitMRInnmannMM, et al. Cortical hypertrophy with a short, curved uncemented hip stem does not have any clinical impact during early follow-up. BMC Musculoskelet Disord2015; 16: 371.
35.
HorwoodNJNamDGrecoNJ, et al. Reduced thigh pain with short femoral stem design following direct anterior primary total hip arthroplasty. Surg Technol Int2019; 34: 437–444.
36.
AmstutzHCThomasBJJinnahR, et al. Treatment of primary osteoarthritis of the hip: a comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am1984; 66: 228–241.
37.
InoueDKabataTMaedaT, et al. The correlation between clinical radiological outcome and contact state of implant and femur using three-dimensional templating software in cementless total hip arthroplasty. Eur J Orthop Surg Traumatol2016; 26: 591–598.
38.
PepkeWNadorfJEwerbeckV, et al. Primary stability of the Fitmore stem: biomechanical comparison. Int Orthop2014; 38: 483–488.
39.
SumnerDRGalanteJO.Determinants of stress shielding: design versus materials versus interface. Clin Orthop Relat Res1992; 274: 202–212.
40.
GosensTSluimerJCKesterAD, et al. Femoral fit predicts radiologic changes, but not clinical results, in Mallory-head total hip arthroplasties. Clin Orthop Relat Res2005; 432: 138–147.
41.
ShinYSSuhDHParkJH, et al. Comparison of specific femoral short stems and conventional-length stems in primary cementless total hip arthroplasty. Orthopedics2016; 39: e311–e317.
42.
YuHLiuHJiaM, et al. A comparison of a short versus a conventional femoral cementless stem in total hip arthroplasty in patients 70 years and older. J Orthop Surg Res2016; 11: 33.
43.
KimYHParkJWKimJS.Ultra-short versus conventional uncemented stems for hip replacement in octogenarians. Orthopedics2018; 41: 28–34.
44.
VresilovicEJHozackWJRothmanRH.Incidence of thigh pain after uncemented total hip arthroplasty as a function of femoral stem size. J Arthroplasty1996; 11: 304–311.
45.
AmendolaRLGoetzDDLiuSS, et al. Two- to 4-year follow up of a short stem THA construct: excellent fixation, thigh pain a concern. Clin Orthop Relat Res2017; 475: 375–383.
46.
IorioRHealyWLWarrenPD, et al. Lateral trochanteric pain following primary total hip arthroplasty. J Arthroplasty2006; 21: 233–236.
47.
Sayed-NoorASSjodenGO.Greater trochanteric pain after total hip arthroplasty: the incidence, clinical outcomes and associated factors. Hip Int2006; 16: 202–206.
