Tm. Keaveny et Dl. Bartel, MECHANICAL CONSEQUENCES OF BONE INGROWTH IN A HIP-PROSTHESIS INSERTEDWITHOUT CEMENT, Journal of bone and joint surgery. American volume, 77A(6), 1995, pp. 911-923
Long-term biomechanical problems associated with the use of sintered p
orous coating on prosthetic femoral stems inserted without cement incl
ude proximal loss of bone and a risk of fatigue fracture of the prosth
esis. We sought to identify groups of patients in whom these problems
are accentuated and in whom the use of porous coating may thus jeopard
ize the success of the arthroplasty. We attempted to develop clinical
guidelines for the use of sintered porous coating by investigating the
long-term biomechanical: effects of bone growth into partially (two-t
hirds) porous-coated anatomic medullary locking hip prostheses that fi
t well. More specifically, we used a detailed finite element analysis
and a composite beam theory to determine tile dependence of proximal l
oading of the bone and maximum stresses on the stem on the development
of clinically observed patterns of bone ingrowth and the dependence o
f the risk of fatigue fracture of the stem on the diameter of the stem
, the diameter of the periosteal bone, and the material from which the
prosthesis was made. We found that bone ingrowth per se substantially
reduced proximal loading of the bone. With typical bone ingrowth, axi
al and torsional loads acting on the proximal end of the bone were red
uced as much as twofold compared with when there was no ingrowth; bend
ing loads on the proximal end of the bone were also reduced. The risk
of fatigue fracture of the stem was insensitive to the development of
bone ingrowth. However, the risk of fatigue fracture of the stem incre
ased with decreased diameters of the stem and the periosteal bone and
with increased modulus of the stem. The maximum risk of fracture was f
ound in active patients in whom a cobalt-chromium-alloy stem with a sm
all diameter had been implanted in a bone with a small diameter. CLINI
CAL RELEVANCE: The stabilizing effects of sintered porous coating may
not justify its use in patients in whom the coating introduces problem
s such as excessive loss of bone and a risk of fatigue fracture of the
prosthesis, Our results provide guidelines for the selection of patie
nts for the use of sintered porous coating with anatomic medullary loc
king devices inserted without cement, First, to minimize the proximal
loss of bone, we do not believe that porous coating of any type should
be used distal to the lesser trochanter when the patient's life expec
tancy is longer than twenty to twenty-five years after the primary rec
onstruction procedure, particularly when a stem with a large diameter
is to be inserted into a bone with a small diameter. Second, to preven
t fatigue fracture of the prosthesis, sintered porous coating should n
ot be used anywhere on a cobalt-chromium-alloy stem that is less than
approximately eleven millimeters in diameter and is to be inserted in
an active or heavy patient in whom the periosteal bone is less than ap
proximately twenty-three millimeters in diameter. While insertion of a
larger stem into a larger bone may be associated with a risk of fract
ure of the prosthesis, depending on the level of activity and the body
weight of the patient, these constraints can be relaxed if a sintered
titanium-alloy prosthesis is used. Taken together, these findings sug
gest that anatomic medullary locking prostheses with sintered porous c
oating are best suited for patients in whom a mid-sized stem will be i
mplanted in a bone with a larger than average diameter.