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Journal of Orthopaedic Science xxx (2015) 1e4

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Case report

The Asian size Exeter femoral stem fracture

Kwong-Yin Chung a, *, Kin-Wing Cheung a, Kwok-Hing Chiu a, Wan-Yiu Shen b
Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Hong Kong
Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hong Kong

a r t i c l e i n f o

Article history: performed at the age of 70 and the left total hip arthroplasty was
Received 29 July 2014 performed at the age of 72. She weighed 71 kg at the time of right
Received in revised form total hip arthroplasty and weighed 78 kg at the time of left total hip
30 January 2015 arthroplasty. The fixations of both hip arthroplasty were in hybrid
Accepted 15 February 2015
Available online xxx
form, using 52 mm Trident PSL HA coated cementless acetabular
shell (Stryker Howmedica Osteonics, Allendale, NJ) reinforced with
one screw and 33 mm offset Exeter femoral stem (Stryker Inc,
Warsaw, IN). Metal on polyethylene articulation with 28 mm
femoral head were used in both hips. Femoral heads with addi-
tional 5 mm length were used in both hips. Simplex P bone cement
(Stryker) and modern cementation technique using pulsatile
lavage, cement restrictor, stem centralizer, vaccum mixing, retro-
1. Introduction
grade filling and pressurization was used in both hips. Intra-
operatively, the femoral stems were well supported by cement
The Exeter femoral stem was in clinical use since 1970 with good
mantle proximal medially. Post-operatively, there was no pain over
result [1]. The collarless, double tapered, polished design allows
both hips. She lived a sedentary lifestyle and could walk with one
controlled subsidence of the femoral stem within the cement
cane for 20 min. The Harris hip score for the right hip improved
mantle. Adequate thickness of cement mantle is critical for the
from 26 to 81 after the operation [5]. The Harris hip score for the
long-term success of Exeter femoral stem. However, the original
left hip improved from 26 to 83 after the operation. Early post-
design was aimed for Western population and stem oversizing was
operative plain radiograph revealed the cement mantle was
common in Asian population with small body build [2e4]. Smaller
Barrack grade B in both hips [6]. The right femoral stem was in 3
Asian size Exeter femoral stem was introduced to fit the Asian
varus alignment and the left femoral stem was in neutral alignment
population. Smaller Asian size stems with 30 mm and 33 mm offset
(Fig. 1). The right acetabular cup was in relatively lateralized posi-
have been made available since 1998. In view of the small size of
tion. Lateral plain radiograph of the right hip showed adequate
the Asian stem, stem fracture is of concern.
cement mantle of more than 2 mm in all zones (Fig. 2).
Here we report a case of Asian size Exeter femoral stem fracture.
She experienced sudden onset of right proximal thigh pain six
Factors contributed to the stem fracture were discussed. Careful
years after the index operation. There was no history of trauma. The
pre-operative planning and meticulous surgical technique should
pain was mechanical, and affected her ambulatory ability. She could
be employed when use of small stem. Biomechanical studies to
only walk with frame for five minutes since she experienced the
define the weight limitation for the smaller Asian size Exeter
symptom. Physical examination revealed her body weight was
femoral stem was recommended. The patient was informed that
78 kg with body mass index of 31.6. There was diffuse focal
data concerning the case would be submitted for publication, and
tenderness over right proximal thigh. There was no sign of focal
she consented.
infection. Pain over right proximal thigh was elicited upon flexion
and rotation of right hip. Plasma white cell count and C-reactive
2. Case report
protein were normal. Bone mineral density was not measured.
Plain radiograph revealed fracture at the junction of proximal one-
A lady suffered from bilateral hip dysplasia underwent bilateral
third and distal two-third of the Exeter stem and there was fracture
total hip arthroplasties. The right total hip arthroplasty was
of proximal medial cement mantle (Fig. 3). The Harris hip score for
the right hip was 23. Revision femoral stem was performed. Intra-
operatively, cement mantle fracture over proximal medial femur
* Corresponding author. Department of Orthopaedics and Traumatology, Prince
of Wales Hospital, Shatin, Hong Kong. Tel.: þ852 2632 2901; fax: þ852 2637 7889. was noted. The medial calcar bone was intact. The proximal part of
E-mail address: (K.-Y. Chung). the fractured stem was easily retrieved, but the distal part was well
0949-2658/© 2015 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Chung K-Y, et al., The Asian size Exeter femoral stem fracture, Journal of Orthopaedic Science (2015), http://
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Fig. 1. Radiograph showing bilateral total hip arthroplasties.

Fig. 3. Radiograph showing right femoral stem fracture.

fixed within the cement mantle. Extended trochanteric osteotomy

was required to retrieve the distal part of the fractured stem. partial weight bear walking exercise for six weeks, followed by
Femoral stem was revised using long stemmed extensively coated weight bearing as tolerated. She recovered well after the revision
cementless Solution stem (DePuy, Warsaw, IN). The extended surgery. The Harris hip score for the right hip was 81 at 3.5 years
trochanteric osteotomy was repaired with cable wires (Fig. 4). She after the revision surgery. The left total hip arthroplasty was
was put on touchdown walking exercise for six weeks, followed by asymptomatic. The Harris hip score for the left hip was 83 at 8 years
after the index operation.

3. Discussion

Exeter femoral stem was in clinical use since 1970 [1]. The initial
design was a collarless, double tapered, polished stem made of 316L
stainless steel. This design was based on the rationale that minimal
load transfer was observed at collar-calcar junction in the cemen-
ted Thompson hemiarthroplasty prosthesis and the McKee-Farrar
total hip arthroplasty, and the double taper geometry increased
the capacity to extrude cement into endosteal bone surface of the
femur. Stem subsidence was not intended in this initial design. It
was only observed during subsequent follow up that distal move-
ment of the stem within cement mantle without disruption of the
cement-bone interface. However, high prosthesis failure rate was

Fig. 2. Lateral radiograph showing the right total hip arthroplasty. Fig. 4. Radiograph showing revision right total hip arthroplasty.

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K.-Y. Chung et al. / Journal of Orthopaedic Science xxx (2015) 1e4 3

noted in this initial design. Eight of 426 (1.87%) Exeter stems chrome stem with the above mentioned risk factors, both of which
implanted from 1970 to 1976 fractured at an average follow up of 13 are revision arthroplasties [15]. Though other authors experienced
years [1], which increased to 3% of the original cohort with a cobalt chrome stem fracture with a different design and fixation
minimum follow up of 20 years [7]. Due to this unexpected high principle [18,19].
failure rate, the stem was modified to matte surface and stronger Chiu published the result of Exeter total hip arthroplasty in
stem with larger anteroposterior diameter in 1976. Stem fracture Chinese patients [2e4]. Small body build, and thus small size femur
dramatically dropped to 0.03% (one in 2968 stems) with this with stem oversizing were common with the Exeter stem originally
modified stem [1], and reported to be 0.22% in the latest available designed for Western population. Oversizing of the stem and
report [7]. Though, in contrary, a high fracture rate of 11% (three in incomplete or inadequate cement mantle might account for the
27 stems) with this modified stem was reported by Røkkum [8]. early loosening. Among 27 stems considered oversized with inad-
However, extensive burnishing on the matte surface due to metal equate or incomplete cement mantle, the failure rate was 22.2%,
and cement debris production by fretting during stem subsidence, while none of those with adequate cement mantle failed [3]. In
leading to increased osteolysis and subsequent aseptic loosening. those 27 oversized stem, smallest size stem in the study period
As a result, polished surface was reintroduced in 1986 and a high were used in 18 hips. 35.5 mm offset Exeter stem have been in use
strength, low corrosion stainless steel (Orthinox) with fatigue since 1997 and two smaller stems with 30 mm and 33 mm offset
properties similar to forged high strength vitallium was used as the (Fig. 5) have been made available to this population since 1998. In
material of the stem. The stem fracture rate of this new design was the subsequent 5 years following its availability, CDH or smaller
extremely low [9e11]. stems were used in 73.2% of Exeter total hip arthroplasties [3]. No
The use of aforementioned high nitrogen stainless steel in the stem failure was observed at the time of Chiu's reporting [3,4].
modern cemented femoral stem aimed at elimination of stem Fujita [20], Sivananthan [21], and Tai [22] from different Asian
failure. However, cases of stem fracture were still observed. Yates centers also reported their results of small Exeter stem implanted
reported 14 cases of fracture with stem made of high nitrogen for primary and revision total hip arthroplasties, with no stem
stainless steel by three different manufacturers, of which 12 were fracture observed. Choy compared the results of Exeter short stems
fractured within the cement mantle [12]. Fractures of the femoral with the standard length Exeter stems from the national joint
stem have been studied and contributing factors were identified replacement registry [23]. One small stem fracture was mentioned,
[12e15], including (1) high stress in stem due to overweight, un- but detail on the cause of failure was not available. Stem fracture is
dersized prosthesis or high level of activity; (2) poor proximal bone a rare event. The rate of small stem fracture in this large series was
support or fixation, which may be due to absence of calcar; (3) 0.066%, and the rate of standard stem fracture was 0.029% [23]. To
varus orientation of the stem; (4) cantilever bending of the stem our knowledge, this is the first report of fracture of Asian size Exeter
resulting from good distal fixation but inadequate proximal cement stem with detail discussion.
mantle; and (5) material defects in the stem itself. One or a com- In the present report, the acetabular cup was in relatively lat-
bination of the above contributing factors leads to the catastrophic eralized position. The proximal cement mantle in the failed stem
failure of the stem in both the early generation, and the newer was noted to be more than 2 mm during the revision surgery. The
implant as reported by Yates [12]. Apart from Yates' report, Raj and stem was placed in 3 varus, which increased the bending moment
van Doorn also reported their isolated case of modern cemented and tensile stress on the implant, might contribute to the fracture.
stem fracture in primary and revision total hip arthroplasty with More meticulous removal of cancellous bone over proximal lateral
impaction allografting respectively [16,17]. femur would allow insertion of stem in neutral alignment and
Stem with similar design and subsidence principle made of co- possibly larger 35.5 mm offset stem. Moreover, the stem was
balt chrome were manufactured. They are stronger, but are not inserted to the distal reference marking and femoral head with
immune from fracture. Jazrawi published the only report of two additional 5 mm length was implanted. Though within the
cases fracture of collarless, tapered, polished cemented cobalt recommendation of the manufacturer, both contributed to the

Fig. 5. (From left to right) Asian size small Exeter stems with 30 mm, 33 mm offset compared to 35.5 mm offset stem and standard 37.5 mm offset stem.

Please cite this article in press as: Chung K-Y, et al., The Asian size Exeter femoral stem fracture, Journal of Orthopaedic Science (2015), http://
4 K.-Y. Chung et al. / Journal of Orthopaedic Science xxx (2015) 1e4

increase in offset and thus bending moment. In addition, a relative [3] Chiu KH, Shen WY, Cheung KW, Tsui HF. Primary Exeter total hip arthroplasty
in patients with small femurs: a minimal of 10 years follow-up. J Arthroplasty
small 33 mm offset stem was implanted into a patient weighed
71 kg, and subsequently her weight increased to 78 kg, with a body [4] Chiu KH, Cheung KW, Chung KY, Shen WY. Exeter small femoral stem for
mass index of 31.6. Though there was no weight restriction posed patients with small femurs. J Orthop Surg (Hong Kong) 2011;19:279e83.
by the manufacturer, we feel that this could be a contributing factor [5] Harris WH. Traumatic arthritis of the hip after dislocation and acetabular
fractures: treatment by mold arthroplasty. An end-result study using a new
to the stem fracture. A combination of the above factors resulted in method of result evaluation. J Bone Jt Surg Am 1969;51:737e55.
the catastrophic failure of the small stem in the present report. [6] Barrack RL, Mulroy RD, Harris WH. Improved cementing techniques and
Extended trochanteric osteotomy was performed to facilitate femoral component loosening in young patients with hip arthroplasty. A 12-
year radiographic review. J Bone Jt Surg Br 1992;74:385e9.
retrieval of the distal part of the fractured stem and removal of [7] Gie GA, Ling RS, Timperley AJ. Stem fracture with the Exeter prosthesis. Acta
cement mantle. However, a period of protected weight bear Orthop Scand 1996;67:206e7.
walking was required after the osteotomy. Also, there are risks of [8] Røkkum M, Bye K, Hetland KR, Reigstad A. Stem fracture with the Exeter
prosthesis. 3 of 27 hips followed for 10 years. Acta Orthop Scand 1995;66:
fracture of osteotomy fragment, migration of the osteotomy frag- 435e9.
ment, Trendelenburg's gait, non-union and trochanteric pain [24]. [9] Hook S, Moulder E, Yates PJ, Burston BJ, Whitley E, Bannister GC. The Exeter
Careful consideration should be made during pre-operative Universal stem: a minimum ten-year review from an independent centre.
J Bone Jt Surg Br 2006;88:1584e90.
planning when use of small stem in overweight patient is antici- [10] Ling RS. The history and development of the Exeter hip. Montreux,
pated. Cementless stem fixation, which allows larger implant, and Switzerland: Stryker; 2004.
stem with modularity between proximal and distal part, which [11] Williams HD, Browne G, Gie GA, Ling RS, Timperley AJ, Wendover NA. The
Exeter universal cemented femoral component at 8 to 12 years. A study of the
allows better matching in champagne glass shaped canal, are
first 325 hips. J Bone Jt Surg Br 2002;84:324e34.
possible alternatives. Special attention to technical details during [12] Yates PJ, Quraishi NA, Kop A, Howie DW, Marx C, Swarts E. Fractures of
stem insertion is also critical for the long-term success of small modern high nitrogen stainless steel cemented stems: cause, mechanism, and
stem. Appropriate removal of cancellous bone allows proper posi- avoidance in 14 cases. J Arthroplasty 2008;23:188e96.
[13] Chao EY, Coventry MB. Fracture of the femoral component after total hip
tioning of the stem in coronal and possibly sagittal plane; and replacement. An analysis of fifty-eight cases. J Bone Jt Surg Am 1981;63:
aggressive removal of cancellous bone to reach the stronger para- 1078e94.
cortical bone allows accommodation of larger stems without [14] Galante JO. Causes of fractures of the femoral component in total hip
replacement. J Bone Jt Surg Am 1980;62:670e3.
compromising the cement mantle [12]. Insertion of stem to [15] Jazrawi LM, Della Valle CJ, Kummer FJ, Adler EM, Di Cesare PE. Catastrophic
appropriate depth and avoid the use of femoral head that increased failure of a cemented, collarless, polished, tapered cobalt-chromium femoral
the offset while maintaining adequate soft tissue tension are also stem used with impaction bone-grafting. A report of two cases. J Bone Jt Surg
Am 1999;81:844e7.
critical. Substitution of stainless steel stem with cobalt chrome [16] Raj D, Coupe BD, Keene GS. Stem fracture of a collarless, polished, double-
stem may also play a role, due to its higher fatigue strength. taper cemented femoral prosthesis: a case report. Acta Orthop Belg
Currently, there are reports of fracture of cobalt chrome stem 2008;74:697e9.
[17] van Doorn WJ, van Biezen FC, Prendergast PJ, Verhaar JA. Fracture of an Exeter
designed for Exeter principle used in revision arthroplasties and stem 3 years after impaction allografting e a case report. Acta Orthop Scand
fracture of cobalt chrome stem with different design and fixation 2002;73:111e3.
principle, but there is no fracture of cobalt chrome stem designed [18] Della Valle AG, Becksac B, Anderson J, Wright T, Nestor B, Pellicci PM,
Salvati EA. Late fatigue fracture of a modern cemented cobalt chrome stem for
for Exeter principle used in primary total hip arthroplasty reported
total hip arthroplasty: a report of 10 cases. J Arthroplasty 2005;20:1084e8.
in literature [15,18,19]. We also recommend the manufacturer to [19] Woolson ST, Milbauer JP, Bobyn JD, Yue S, Maloney WJ. Fatigue fracture of a
perform biomechanical studies on the smaller Asian size Exeter forged cobalt-chromium-molybdenum femoral component inserted with
stem and recommend the body weight limitation which the small cement. A report of ten cases. J Bone Jt Surg Am 1997;79:1842e8.
[20] Fujita H, Katayama N, Iwase T, Otsuka H. Multi-center study of use of the
stem can tolerate. Exeter stem in Japan: evaluation of 1000 primary THA. J Orthop Sci 2012;17:
[21] Sivananthan S, Arif M, Choon DS. Small stem Exeter total hip replacement:
Conflict of interest clinical and radiological follow-up over a minimum of 2.5 years. J Orthop Surg
(Hong Kong) 2003;11:148e53.
[22] Tai CC, Nam HY, Abbas AA, Merican AM, Choon SK. First series of Exeter small
The authors declare that they have no conflict of interest.
stem primary total hip arthroplasty minimum 5 years of follow-up.
J Arthroplasty 2009;24:1200e4.
[23] Choy GG, Roe JA, Whitehouse SL, Cashman KS, Crawford RW. Exeter short
References stems compared with standard length Exeter stems: experience from the
Australian Orthopaedic Assoication National Joint Replacement Registry.
[1] Fowler JL, Gie GA, Lee AJ, Ling RS. Experience with the Exeter total hip J Arthroplasty 2013;28. 103e109.e1.
replacement since 1970. Orthop Clin North Am 1998;19:477e89. [24] Mardones R, Gonzalez C, Cabanela ME, Trousdale RT, Berry DJ. Extended
[2] Chiu KH, Shen WY, Tsui HF, Chan KM. Experience with primary Exeter total femoral osteotomy for revision of hip arthroplasty: results and complications.
hip arthroplasty in patients with small femurs. Reviews at average follow-up J Arthroplasty 2005;20:79e83.
period of 6 years. J Arthroplasty 1997;12:267e72.

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