Risk factors for femoral stem fracture following total hip arthroplasty: a systematic review and meta analysis

Abstract

Background
Femoral stem fracture following total hip arthroplasty (THA) is an infrequent but nevertheless devastating complication, with an increasing worldwide prevalence as demand for primary THA continues to increase. The aim of this study was to perform a systematic review and meta-analysis of risk factors for femoral stem fracture to help identify at risk patients.

Methods
A systematic search was conducted on EMBASE, MEDLINE and AMED to identify relevant studies. Data regarding study design, source, population, intervention, and outcomes was collated. Data extraction was performed on a custom form generated using Cochrane recommended methodology and analysis of risk factors performed including odds ratios (ORs) with 95% confidence intervals (CIs).

Results
A total of 15 studies reporting a total of 402 stem fractures in 49 723 THAs were identified. The median time from index procedure to stem fracture was 68 months (IQR 42.5–118) whilst mean age at index surgery was 61.8 years (SD 6.9). Male gender (OR = 3.27, 95% CI = 2.59–4.13, p < 0.001), patient weight above 80 kg (OR = 3.55, 95% CI = 2.88–4.37, p < 0.001), age under 63 years (OR = 1.22, 95% CI = 1.01–1.49, p < 0.001), varus stem alignment (OR = 5.77, 95% CI = 3.83–8.7, p < 0.001), use of modular implants (OR = 1.95, 95% CI = 1.56–2.44, p < 0.01) and undergoing revision arthroplasty (OR = 3.33, 95% CI = 2.70–4.1, p < 0.001) were significant risk factors for prosthetic stem fracture. A risk window of 15 years post-surgery was identified.

Conclusions
This review concludes that patient weight, younger age, male sex, varus stem alignment, revision arthroplasty and use of modular stems are significant risk factors for femoral stem fracture. Modifying these risk factors where possible may help reduce incidence of femoral stem fracture in at risk patients.

Full text

Vol.:(0123456789)
Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
https://doi.org/10.1007/s00402-024-05281-x
HIP ARTHROPLASTY
Risk factors forfemoral stem fracture followingtotal hip arthroplasty:
asystematic review andmeta analysis
GarethS.Turnbull1,3 · SamSoete1· MuhammadAdeelAkhtar2· JamesAndersonBallantyne2
Received: 25 August 2023 / Accepted: 10 March 2024 / Published online: 12 April 2024
© The Author(s) 2024
Abstract
Background Femoral stem fracture following total hip arthroplasty (THA) is an infrequent but nevertheless devastating com-
plication, with an increasing worldwide prevalence as demand for primary THA continues to increase. The aim of this study
was to perform a systematic review and meta-analysis of risk factors for femoral stem fracture to help identify at risk patients.
Methods A systematic search was conducted on EMBASE, MEDLINE and AMED to identify relevant studies. Data regard-
ing study design, source, population, intervention, and outcomes was collated. Data extraction was performed on a custom
form generated using Cochrane recommended methodology and analysis of risk factors performed including odds ratios
(ORs) with 95% confidence intervals (CIs).
Results A total of 15 studies reporting a total of 402 stem fractures in 49 723 THAs were identified. The median time from
index procedure to stem fracture was 68 months (IQR 42.5–118) whilst mean age at index surgery was 61.8 years (SD 6.9).
Male gender (OR = 3.27, 95% CI = 2.59–4.13, p < 0.001), patient weight above 80 kg (OR = 3.55, 95% CI = 2.88–4.37,
p < 0.001), age under 63 years (OR = 1.22, 95% CI = 1.01–1.49, p < 0.001), varus stem alignment (OR = 5.77, 95% CI = 3.83–
8.7, p < 0.001), use of modular implants (OR = 1.95, 95% CI = 1.56–2.44, p < 0.01) and undergoing revision arthroplasty
(OR = 3.33, 95% CI = 2.70–4.1, p < 0.001) were significant risk factors for prosthetic stem fracture. A risk window of 15
years post-surgery was identified.
Conclusions This review concludes that patient weight, younger age, male sex, varus stem alignment, revision arthroplasty
and use of modular stems are significant risk factors for femoral stem fracture. Modifying these risk factors where possible
may help reduce incidence of femoral stem fracture in at risk patients.
Keywords Stem fracture· Implant failure· Arthroplasty· Modular stem· Implant
Introduction
The reported incidence of femoral stem fracture after total
hip arthroplasty (THA) currently ranges from under 0.1 to
3.4%, [1–4] although historically much higher rates have
been reported above 10% [5]. The low rate of stem fracture
in modern implants has been attributed in part to advances
in stem design, metallurgy and cementing techniques [6].
Despite this, rising worldwide demand for THA means
the prevalence of stem fractures is expected to increase [7,
8]. Understanding risk factors for stem fracture therefore
remains clinically important in order to help minimise risk
of this devastating complication to patients.
Femoral stem fracture is generally thought to occur due to
fatigue generated by unfavourable biomechanics. For exam-
ple, mechanical overload has been recognised to predispose
to implant neck fracture [9]. Loss of proximal support with
a well-fixed distal stem can also allow repeated cantilever
bending and access of body fluid salts to the area of stress.
This can promote localized corrosion, fretting and fatigue
crack initiation leading to stem failure (Fig.1) [10]. Previ-
ously noted risk factors for stem fracture can be subdivided
* Gareth S. Turnbull
gareth.turnbull@nhs.scot; gsturnbull@live.com
Sam Soete
samsoete@gmail.com
1 National Treatment Centre-Fife Orthopaedics, Victoria
Hospital, Hayfield Road, KirkcaldyKY25AH, UK
2 The Royal Infirmary ofEdinburgh, 51 Little France Cres,
Old Dalkeith Rd, EdinburghEH164SA, UK
3 Department ofTrauma andOrthopaedics, The University
ofEdinburgh, 49 Little France Crescent, Old Dalkeith Road,
EdinburghEH164SA, UK
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2422 Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
into three categories with patient, implant and surgical fac-
tors all thought to contribute. Patient gender, body mass
index (BMI), activity levels and reduced proximal bone
stock in context of revision THA have all been noted to
increase risk [2, 3, 11]; implant factors including stem
design, materials, modularity and reliance on cementless
or cemented fixation have also been noted to influence risk
[12]; finally, surgical factors including varus malpositioning
of the stem, implant undersizing and inadequate cementing
technique have also been found to increase risk [1].
Identifying risk factors for stem fracture and modifying
them where possible forms part of a wider strategy to help
reduce risk of subsequent revision surgery in patients, with
revision THA associated with increased costs and poorer
outcomes when compared to primary THA [13, 14]. The
aim of this study is therefore to perform a systematic review
and meta-analysis of risk factors for femoral stem fracture to
help identify at risk patients.
Methods
A systematic literature search was performed for studies
that reported femoral stem fracture following THA using
selected search terms including arthroplasty, fracture and
stem (Fig.2) The following databases were searched:
EMBASE (from 1974), MEDLINE (from 1946) and AMED
(1985).
Duplicates were removed and search results reviewed
using COVIDENCE software in order to categorize poten-
tially appropriate abstracts. A second full-text screening
was performed alongside inclusion and exclusion criteria to
identify relevant articles. Reference lists of included papers
were also screened to discover any articles that were missed
in the initial search.
Studies were excluded if they did not: (1) analyse poten-
tial risk factors for prosthetic stem fracture, (2) provide
individual participant data on those with stem fractures, (3)
analyse the appropriate age group (> 18 years old), or (4)
differentiate between stem fracture and dislocation.
Quality assessment
All included studies were appraised for their quality by
two authors using the Critical Appraisal Skills Programme
(CASP) checklist specific for cohort studies (Table1). The
assessment tool uses 10 questions to assess study design,
validity of results and generalisability to a wider popula-
tion with the goal of uncovering systematic points of failure
[15]. All included studies in this review were observed to be
methodologically satisfactory.
Statistical analysis
This was performed using Statistical Package for Social
Sciences version 28.0 (SPSS Inc., Chicago, Illinois). Het-
erogeneity between studies was tested using pre-operative
parameters of age, follow-up duration and sex using the
I2 index based on Cochran’s Q with an I2 index greater
than 50% deemed heterogenous. Univariate analysis was
Fig. 1 Examples of broken prosthetic stems
Fig. 2 Preferred Reporting Items for Systematic reviews and Meta-
Analyses flow diagram showing the study selection process
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2423Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
Table 1 Qualitative assessment of included studies. ( +) indicate positive assessments, empty box represents an inability to answer the question based on presented data, whilst (−) indicates a
negative result
CASP cohort
study checklist
Did the study
address a
clearly focused
issue?
Was the cohort
recruited in an
acceptable way?
Were the
outcomes accu-
rately measured
to minimise
bias?
Have they taken
account of the
confounding
factors in the
design and/or
analysis?
Was the follow
up of subjects
complete
enough?
Was the follow
up of subjects
long enough?
Are the
results precise
enough?
Do you
believe the
results?
Can the results
be generalised
to a wider
population?
Do the results of
this study fit with
other available
evidence?
Amstutz etal.
[18]
+ + + + + + + + + +
Busch etal. [2] + + + + + + + + −
Krüger etal.
[16]
+ + + + + + + + + +
Shah etal. [19] + + + + + + + + +
Røkkum etal.
[20]
+ + + + + + + + − −
Herold etal.
[17]
+ + + + + + + + +
Kishida etal.
[21]
+ + + + + + + + −
Lakstein etal.
[1]
+ + + + + + + + + +
Matar etal. [22] + + + + + + + + +
Merini etal.
[23]
+ + + + + + + + + +
Pazzaglia etal.
[24]
+ + + + + + + + + +
Ritter etal. [25] + + + + + + + + +
Vanbiervliet
etal. [26]
+ + + + + + + + + +
Wroblewski
etal. [11]
+ + + + + + + + +
Yates etal. [9] + + + + + + + + + +
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2424 Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
performed using parametric (Student’s t-test: paired and
unpaired) and non-parametric (Mann–Whitney U test)
tests, as appropriate, to assess continuous variables for sig-
nificant differences between two groups. Nominal categor-
ical variables were assessed using a chi-squared or Fisher’s
exact test. Pearson’s correlation or Spearman’s rank cor-
relation were used to assess the relationship between linear
variables as appropriate. Odds rations were calculated to
examine the association between stem fracture and differ-
ent risk factors with corresponding 95% confidence inter-
vals also calculated. The data were standardized to means
and SDs, weighted for sample size. A p-value of < 0.05
was considered significant in all analyses.
Results
There were 385 articles identified in the initial search after
duplicates were removed. After primary screening of titles
and abstracts, 15 articles meeting the inclusion criteria
were identified [2]. The year of publication ranged from
1982 to 2020. Fourteen of the included papers were retro-
spective studies and one study was prospective in nature.
Some studies limited their assessment to an individual
prosthesis, whilst others compared the performance of dif-
ferent stem designs (Table2). Krüger etal. [16], Herold
etal. [17] and Yates etal. [9] compared the stem fracture
group to a separate control group (Table2). The number of
stem fractures reported in included studies ranged between
3 and 120.
Stem fractures
Initial analysis was performed to allow consideration of
study weighting and heterogeneity with respect to stem
fracture risk. Similar risk profiles were present for stem
fracture throughout all included studies (Fig.3). A total of
402 stem fractures in 49 723 THAs were identified, giving
an overall stem fracture rate of 0.8% (range 0.3–11%). The
median time from index procedure to stem fracture was 68
months (IQR 42.5–118) whilst mean age at index surgery
was 61.8 years (SD 6.9). Whilst operative indication and
demographic data was incompletely reported in some stud-
ies, osteoarthritis was the most frequent reported indica-
tion for index surgery (1538/2185) followed by rheumatoid
arthritis (104/2185) and AVN (114/2185). Primary THA
was noted in 9539 cases and revision THA in 2857 cases.
Male sex was reported in 2110 THAs and female in 2232
THAs. 309/402 stem fractures (77%) across the included
studies occurred in male participants.
Risk factors forstem fracture
Several patient factors were found to significantly increase
risk for stem fracture on analysing pooled summary data
from included studies (Fig.4). Patients suffering stem
fracture were significantly younger (p < 0.05, non-frac-
tured stems age 64.4 ± 6 (SD) years vs fractured stems
63.1 ± 8.3) with those age under 63 years having a signifi-
cantly increased odds ratio (OR) for suffering stem fracture
(OR = 1.22, 95% CI = 1.01–1.49, p < 0.001). Patients suffer-
ing stem fracture also had significantly higher average weight
(p < 0.05, non-fractured stems 71.1 ± 8 kg vs fractured stems
94.1 ± 16.9) with those above 80 kg having a significantly
increased odds ratio (OR = 3.55, 95% CI = 2.88–4.37,
p < 0.001). Male gender was also a significant risk factor for
stem fracture (OR = 3.27, 95% CI = 2.59–4.13, p < 0.001),
with 77% of fractured stems occurring in male patients.
In terms of surgical factors, fractured stems were signifi-
cantly more likely to be in a varus alignment (OR = 5.77,
95% CI = 3.83–8.7, p < 0.001). Stem fracture was also sig-
nificantly more likely to occur in the setting of revision THA
(OR = 3.55, 95% CI = 2.88–4.37, p < 0.001). Fur thermore,
use of modular stems also carried increased risk of stem
fracture (OR = 1.95, 95% CI = 1.56–2.44, p < 0.01).
Discussion
The results of our study highlight that several factors pre-
dispose to increased risk of femoral stem fracture. Some
patient risk factors are clearly non-modifiable, such as male
sex and patients requiring THA at a young age. However,
there are potential steps that can be taken to reduce risk even
in these patients.
The most significant risk factor for fracture on perform-
ing meta-analysis appeared to be placing the femoral stem
in varus alignment. Previous studies have demonstrated that
varus alignment increases the stress placed on the femoral
stem [9, 27]. Clinically that has translated in case series to an
increased observed rate of stem fracture in those with varus
alignment [6, 11, 22, 24, 25]. Our study found that varus
alignment acts as a statistically significant risk factor for
femoral stem fracture, with 48% of fractured stems having
varus alignment. Markolf etal. observed a 32.7% increase of
bending force in long necks placed in a varus position dem-
onstrating a mechanism for this finding [27]. Contrastingly,
Wroblewski etal. noted that stems with valgus alignment
fractured significantly sooner than their varus counterparts.
However, it was noted that the stems in valgus alignment
belonged to heavier patients [11].
Increased patient weight was also found to be a significant
risk factor for stem fracture. The role of obesity in increasing
patient risk of complications including infection, delayed
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2425Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
wound healing, periprosthetic fracture and reoperation has
been well described previously [3, 9, 13, 22]. Charnley pre-
viously observed a significantly higher stem fracture rate
in participants weighing over 88kg [11]. This is in keep-
ing with our findings of a significant average difference in
patient weight of 23kg between non-fractured and fractured
stem groups (71.1 ± 8, 94.1 ± 16.9). Several other case series
have also noted obesity as a significant risk factor for pros-
thetic stem fracture [22, 24, 26, 29].
Patients undergoing revision THA also appeared to be at
increased risk of stem fracture. Proximal implant support
may be reduced and implant strain increased in revision
THA due to bone loss from infection, aseptic loosening,
or indeed due to trochanteric osteotomies. If trochanteric
osteotomies are indicated in the presence of unsatisfac-
tory proximal bone support, it has therefore been suggested
that reinforcement such as in the form of a strut graft is
considered [22]. It has also been suggested that the use of
small-diameter stems should be avoided in revision THA,
especially in patients with other risk-factors for stem fracture
such as obesity [22, 24, 29]. Modular implants commonly
used in revision THA also had significantly increased risk
Table 2 Summary data of included studies
Year Author Total thrs Stem fractures Study length Follow-up time (months) Description of prosthesis included
1990 Amstutz etal.[18] 716 13 1970–1978 64 (12–180) Trapezoidal-28 stem. Primary
cemented monoblock stainless
steel femoral stem
2005 Busch etal. [2] 219 5 Not recorded Not recorded Cobalt-chrome diaphyseal fixed
revision stems: 151 solution
(DePuy) & 68 Echelon (Smith &
Nephew)
2020 Krüeger etal. [16] 37,600 110 2010–2017 > 60 Titanium alloy revison stem: MRP-
TITAN, Peter Brehm GmbH
Titanium alloy, uncemented modu-
lar revision femoral stem
Demographic data only presented
for stem fracture patiets and
matched cohort (273 patients in
total)
2017 Shah etal. [19] 1177 9 2005–2011 Not recorded Titanium alloy revison stem: 547
Emperion (Smith & Nephew) &
621 S-ROM (DePuy)
1995 Røkkum etal. [20] 27 3 1983–1985 108–132 Exeter stem, composed of stainless
high-nitrogen steel
2021 Herold etal. [17] 1009 32 2002–2017 Not recorded Revitan stem (Zimmer Biomet
GmbH), a titanium alloy modular
revision stem
2002 Kishida etal. [21] 204 5 1987–1995 Not recorded Lubeck, a cobalt–chrome–molyb-
denum alloy stem used in
primary THA
2011 Lakstein etal. [1] 179 6 1999–2009 > 24 Titanium alloy revison stem: ZMR
(Zimmer)
2020 Matar etal. [22] 3229 35 2008–2018 Not recorded 15 Polished tapered cemented
stems & 10 composite beam &
10 miscellaneous stems
2016 Merini etal. [23] 302 16 2002–2003 10 (1–11) Hydroxyapetite coated titanium
cementless Corail femoral stems
with laser neck etching (2nd gen,
2002)
1988 Pazzaglia etal. [24] 365 13 1969–1976 108–192 9 Charnley & 4 Mueller
1986 Ritter etal. [25] 273 14 1974–1980 Not recorded Stainless steel trapezoidal-28
(Zimmir)
2020 Vanbiervliet etal. [26] 315 7 2010–2017 69 Stainless steel fortress stem
1982 Wroblewski etal. [11] 3983 120 Not recorded Not recorded Stainless steel Charnley “flat back”
2008 Yates etal. [9] 125 14 1995–2000 92 with mean 56, 111 with mean
120
Modern, high-nitrogen, stainless
steel stems
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2426 Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
Fig. 3 Forest plot (A) and
corresponding breakdown of
random-effects REML model
(B) examining stem fracture
risk of included studies in meta
analysis and study weighting
(A)
(B)
Random-effects REML model
Heterogeneity : Tau squared = 0.00, dF = 14,
Test of overall effect size : z = -4.85, p <0.001
Author
Stem
Fracture Rate
(%)
Log Risk Rao With 95%
Confidence Interval Weight (%)
Amstutz et al. 2-1.51 (-4.57, 1.54)6.48
Busch et al. 2-1.69 (-4.71, 1.32)6.66
Krüeger et al. 0.3 -0.47 (-4.00, 3.06)4.85
Shah et al. 1-0.92 (-4.20, 2.35)5.65
Røkkum et al. 11 -3.03 (-5.91, -0.15) 7.29
Herold et al. 3-1.96 (-4.92, 0.99)6.93
Kishida et al.2-1.75 (-4.75, 1.25)6.71
Lakstein et al. 3-2.01 (-4.96, 0.95)6.94
Matar et al.1-1.14 (-4.32, 2.04)5.99
Merini et al. 5-2.40 (-5.29, 0.50)7.24
Pazzaglia et al.3-2.06 (-5.00, 0.88)7.00
Rier et al.5-2.37 (-5.27,0.53) 7.22
Vanbiervliet et
al.
2-1.67 (-4.69, 1.35)6.64
Wroblewski et al. 3-1.92 (-4.88, 1.04)6.90
Yates et al.1-3.03 (-5.88, -0.19) 7.50
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2427Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
of stem fracture, in keeping with previous literature. Whilst
modular implants allow more greater flexibility in recon-
structing the native hip in the setting of bony defects in par-
ticular, corrosion at the modular junction has been noted to
increased risk of implant fracture and failure [22, 28, 29].
In terms of time to stem fracture, median time from index
procedure to fracture was 68 months. Overall, 83% of stem
fractures were seen to occur before 10 years, with a very
small number occurring beyond 15 years. Wroblewski etal.
Previously described an 11-year “at risk” period as the vast
majority of fractures within their study occurred within this
timeframe [11]. The varying length of follow up performed
by the studies in this review makes it difficult to comment
on long term stem fracture risk. However, the data available
does suggest fracture is a more often a medium rather than
short or long term complication to be aware of in at risk
patients.
The role patient factors may play in accelerating time to
fracture has also been investigated. Wroblewski etal. meas-
ured weight gain over time after THA given that weight is
not static and can therefore be a dynamic risk factor [11],
reporting a linear and significant relationship between
weight and time to fracture. However, Krüger etal. observed
no significant impact of BMI on the time elapsed post-oper-
atively for stems to break [16]. Our study found a near sig-
nificant trend towards increased weight leading to quicker
stem fracture (r = −0.278, p = 0.08). The influence of other
confounding factors was however difficult to account for. For
example, patient activity levels are infrequently reported in
the literature; this is despite suggestions in some case series
that increased activity levels lead to increased stem fracture
risk, particularly in younger, heavier male patients [22, 25].
There are limitations to our findings. The heterogene-
ity of the studies and stems included made it difficult to
account for the impact of confounding variables on results.
For example, there was a lack of reported data on pro-
posed risk factors for stem fracture including patient activ-
ity levels, stem sizing (including stem length, volume and
use of higher offset or lateralized components) or indeed
occurrence of undersizing, and quality of cement mantle
achieved. Limited data was also available on the quality
of proximal femoral bone stock in stem fracture patients,
which in the context of revision surgery is likely to sig-
nificantly impact upon the cantilever forces implants are
subject to. Due to data limitations, it was also not possible
to comment on any impact related to the use of implants
being combined from different manufacturers within the
same hip construct. Many of the studies included unique
measurements of risk factors making it impractical to con-
duct a meta-analysis on them. Length of follow up was
also variable between studies, whilst some stems have
been superseded in clinical practice by more modern ver-
sions. For example, manufacturer reported fracture rates
of the modern Exeter Universal stem are around 0.0006%
which is significantly lower than in older versions of the
stem [20, 30]. Individual femoral stems are all subject to
their own manufacturing processes and individual risk
profiles, and it will remain important for the surgeon to
remain aware of these during implantation and longer-term
follow-up in the future as femoral implants continue to
evolve.
In conclusion, this study confirmed several significant
risk factors exist for femoral stem fracture. Risk may be
minimised by avoiding varus stem alignment, careful use
of modular implants in revision THA, and encouraging
pre-operative weight loss especially in heavier, young male
patients.
Author contributions GST: Data acquisition, Analysis and interpreta-
tion of data, manuscript preparation. SS: Study design, data acquisi-
tion, analysis and interpretation of data, manuscript preparation. MAA:
Manuscript preparation and revision. JAB: Manuscript preparation and
revision.
Funding No funding was received to perform this study.
Conflict of interest No conflicts of interest declared.
Fig. 4 Forest plot of risk factors
for stem fracture. Odds ratio
and 95% confidence intervals
displayed
123456
7
8
9
Male Sex
Age<63 yrs
Weight
>80kg
Varus
Revision THA
Modularstem
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2428 Archives of Orthopaedic and Trauma Surgery (2024) 144:2421–2428
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