International Orthopaedics
https://doi.org/10.1007/s00264-024-06136-1

ORIGINAL PAPER

Experimental periprosthetic fractures with collarless polished tapered
cemented stems
Takuma Yagura1 · Kenichi Oe1
Takanori Saito1· Fumito Kobayasi1 · Shohei Sogawa1 · Tomohisa Nakamura1 · Hirokazu Iida1 ·Received: 31 January 2024 / Accepted: 29 February 2024
© The Author(s) under exclusive licence to SICOT aisbl 2024

Abstract
Purpose After cemented total hip arthroplasty, the risk of periprosthetic fracture (PPF) of taper-slip stems is higher than thatof composite-beam stems. We aimed to assess the conditions resulting in PPFs of taper-slip stems using a falling weight.
Methods Taper-slip stems were fixed to five types of simulated bone models using bone cement, and the fractures were
evaluated by dropping stainless-steel weights from a predetermined height onto the heads. The periprosthetic fracture heightin 50% of the bone models ­(PPFH50) was calculated using the staircase method.
Results For the fixation with 0° of flexion, the values for ­PPFH50 were 61 ± 11, 60 ± 13, above 110, 108 ± 49, and 78 ± 12 cm
for the cobalt–chromium–molybdenum alloy, stainless steel alloy (SUS), titanium alloy (Ti), smooth surface, and thickcement mantle models, respectively; for the fixation with 10° of flexion (considering flexure), the ­PPFH50 values were 77 ± 5,85 ± 9, 90 ± 2, 89 ± 5, and 81 ± 11 cm, respectively. The fracture rates of the polished-surface stems were 78.6 and 35.7%
at the proximal and distal sites, respectively (p < 0.05); the fracture rates of the smooth-surface stems were 14.2 and 100%,
respectively (p < 0.05).
Conclusion The impact tests demonstrated that the conditions that were less likely to cause PPFs were use of Ti, a smoothsurface, a thick cement mantle, and probably, use of SUS.
Keywords Bone cement · Falling-weight impact test · Periprosthetic fracture · Staircase method · Taper-slip stem

Introduction
Currently, “revisiting” cemented total hip arthroplasty(THA) is a worldwide trend, although many uncemented
THAs has been performed around the world [1]. Cemented
stems are preferable to uncemented stems in terms of theincidence of periprosthetic fractures (PPFs). In a large retrospective study of over 30,000 patients who underwent THAs
at the Mayo Clinic [2], intraoperative PPF occurred up to
three times more often in uncemented stems. According to
the Nordic Arthroplasty Register Association database of
437,629 patients who underwent THAs, the incidence of
PPF after two years of THA conducted using uncemented
and cemented stems was 0.47 and 0.07%, respectively [3].
* Kenichi Oeoeken@hirakata.kmu.ac.jp
1

Department of Orthopaedic Surgery, Kansai Medical
University, 2‑5‑1 Shinmachi, Hirakata, Osaka 573‑1010,
Japan

The American Joint Replacement Registry database of
10,277 patients who underwent revision THAs also reported
that patients with uncemented stems were 2.6 times more
likely to undergo early revision of PPF than those withcemented stems [4]. However, for cemented stems, someauthors have reported that the risk of PPF of taper-slip
stems was high compared to that of composite-beam stems[3, 5–9].
Regarding the mechanism of cement fixation, the designof a cemented stem is based on two ideas: the compositebeam or shape-closed design developed by Charnley andthe taper-slip or force-closed design based on the Exeter
stem [10]. These two types differ in terms of the location of
the shear force, as the composite-beam stem and the bone
cement behave as a single piece at the cement–bone interface, whereas the taper-slip stem slips on the bone cement
because of its polished shape, and thus, applies a shear force
to the stem–cement interface. This small degree of slippingof the taper-slip stem creates compressive hoop stress, whichis thought to affect the long-term performance of the stem
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International Orthopaedics[11]. Although taper-slip stems are widely used and referred
to as the gold standard for cemented stems, differences incement fixation may lead to the occurrence of PPF.
Oe et al. reported some “atypical” PPFs of taper-slip
stems that did not cause any trauma but resulted in excessive
taper-slip [12]. Hirata et al. demonstrated that the effect of
the surface appearance of the stem-cement interface differed
for each metal, even if the roughness of the implant surface
was equal [13]. Kaneuji et al. also performed dynamic loading tests using stainless steel alloy (SUS) and cobalt–chromium–molybdenum alloy (CoCr) stems of similar shapes
and observed differences in the subsidence and forces at thebone–cement interface [14]. Their material and biomechanical studies suggested that a polished-tapered stem made of
CoCr might cause excessive taper-slip on the cement, potentially resulting in PPF. However, PPF of taper-slip stems
could be associated with other risk factors, including thesurface roughness and thickness of the cement mantle. In
this study, we aimed to identify the conditions resulting in
PPF of taper-slip stems using a falling weight.

Materials and methods
Preparation of simulated bone models
The study design was not approved by the appropriate ethics
review board because of no research involving human andanimal subjects. An SC-stem (Kyocera Co., Kyoto, Japan)
Fig. 1  Photographs of the stimulated bone model prepared forthis study. a The SC-stem (size,#STD-3) has a curved tripletapered design and is made ofcobalt–chromium–molybdenum
alloy. b The simulated bone israsped using a broach. c The
stem is fixed to the simulatedbone using bone cement. Thereafter, the stem was removed,
wetted with normal saline, andreinserted into the bone cement
using the in-cement technique

was used. The regular SC-stem had a curved triple-tapered
design, was made of CoCr, and had a polished surface. The
vertical stem length from the centre of the head to the stem
tip was 135 mm (size: STD-3), and the horizontal off-set
length from the centre of the head to the centre of the shaft
was 38 mm. After rasping, the stem was fixed to the simulated bone (Sawbones-femur-medium-left; model number:
1121-3; Pacific Research Laboratories, Vashon, WA, USA)using bone cement (Ostron II; GC Co., Tokyo, Japan) witha centraliser. Under standard conditions, the cement-mantle thickness, which was calculated using the difference
between the rasp and implant sizes, was 1 mm in the shaft
and 3.1 mm in the calcar. After 30 min of bone–cement
hardening, the stem was removed using an extraction tool.
To mimic the wet conditions of the in vivo femoral environment, a stem wetted with normal saline was reinserted
into the bone cement using the in-cement technique, without
adding extra bone cement [15]. Because the stem–cement
interface of a taper-slip stem is contaminated with liquid inclinical practice, the in-cement technique was used to reproduce this phenomenon. A 32-mm metal head was attachedto the SC-stem (Fig. 1).

Conditions of simulated bone models
All implanted stems had the same shape (SC-stem; #STD-3).
Five types of simulated bone models were prepared as follows: (1) standard conditions; CoCr, (2) SUS, (3) titanium
alloy (Ti), (4) smooth surface, and (5) thick cement mantle

International Orthopaedics
Table 1  Conditions of simulated bone models
Conditions

BroachMaterial

Surface roughness

Cobalt–chromium–molybdenum alloy
Stainless steel alloy
Titanium alloy
Smooth surface
Thick cement mantle

STD-3

CoCr

Polished

STD-3
STD-3
STD-3
STD-4

SUS
Ti
CoCr
CoCr

Polished
SmoothSmoothPolished(Table 1). Commercially available SC-stems are made ofboth CoCr and Ti (Ti–15Mo–5Zr–3Al). Although polished
CoCr stems are generally used, Ti stems with smooth surfaces are also available. The Kyocera company approved
this study and provided “SUS” and “smooth-surface CoCr”
stems, based on a computer-aided design. The SUS stem
was made of SUS316. A stem with a smooth surface wasfabricated using the glass bead blasting technique. Surface
roughness was randomly measured at three points on eachstem using a Formtracer Avant S3000 tester (Mitutoyo Co.,
Kanagawa, Japan). The mean surface roughness (Ra; μm)
values were 0.006 ± 0.0006 under the standard condition(CoCr stem), 0.023 ± 0.006 for the SUS stem, 0.314 ± 0.0411
for the Ti stem, and 0.304 ± 0.0405 for the smooth surface
stem. The thick cement mantle was created using a broach(STD-4).

Falling‑weight impact test
The angle positions of the simulated bone models were
determined using a digital inclinometer (DGL-C; Myzox
Co., Aichi, Japan), and the simulated bone models were
fixed within a metal box using bone cement (Ostron II;
Fig. 2). After setting of the bone models, the fractures inthe bone models were evaluated by dropping stainless-steel
weights from a predetermined height onto the heads. The
simulated bone models were fixed at two angles. In one condition, they were fixed at 0° flexion and 13° adduction, suchthat the head was at the vertical position of the fixed end of
the simulated bone (Experiment 1). In the second condition,
they were fixed at 10° flexion and 0° adduction, considering
the flexure of the simulated bone models (Experiment 2).
A 1.5-kg weight (65 mm in diameter × 57 mm) was used
for Experiment 1, whereas a 3-kg weight (65 mm in diameter × 114 mm) was used for Experiment 2. For Experiment 1,
a 2-kg weight was initially used, which was changed to a 1.5kg weight because many fractures were observed. Regarding
Experiment 2, a 1.5-kg weight could not break the simulatedbone models pre-experimentally because, in the flexion position, the load point was outside the simulated-bone fixation position, and the impact was released owing to flexureof the simulated bone. Therefore, the weight was changed

Fig. 2  Photograph showing fixation of the simulated bone model(Experiment 2: 10° of flexion and 0° of adduction). Angle positionsof the simulated bone models were determined using a digital inclinometer (DGL-C; Myzox Co., Aichi, Japan). Subsequently, the simulated bone models were fixed within a metal box using a bone cement(Ostron II, GC Co., Tokyo, Japan)

to 3.0 kg. The weight was suspended by a string inside anacrylic pipe with an inner diameter of 68 mm at a predetermined height, and then, the weight was dropped by cutting
the string (Fig. 3).

Fracture site characteristics
For Experiment 1, the weight was loaded vertically at the
fixed end of the simulated bone, and thus, the bone was
likely to be impacted because there was no route for escapefrom the loading. In Experiment 2, the fracture sites of thebroken simulated bones were assessed because characteristic
fractures were observed. The fracture sites were divided into
two groups: proximal vertical and distal transverse fractures.

Statistical analysis
To assess the conditions influencing PPF of taper-slip stems,
in each group, the periprosthetic fracture height in 50% of
the bone models (­ PPFH50) was calculated using the staircase

International Orthopaedics
Fig. 3  Photographs of thefalling-weight impact test. a
The stimulated bone is fixed
to a tester. b The weight issuspended by a string inside anacrylic pipe at a predeterminedheight. c The simulated bonemodels are fixed at two different
angles (experiments 1 and 2)

method (sequential up-and-down technique) [16]. The procedure for the staircase method was as follows: (1) fractures inthe bone models were evaluated by dropping a weight froma predetermined height; (2) if the specimen was broken, thenext specimen was tested by placing it at a position 10 cm
lower than the previous one, whereas if the specimen was
not broken, the next specimen was tested by placing it at a
position 10 cm higher than the previous one; and (3) thisprocedure was repeated ten times using ten bone models(Fig. 4). ­PPFH50, which was calculated based on the numberof fractured or non-fractured specimens at different heights,
was defined as

PPFH50 = Ha + ΔH(A∕N ± 0.5)
where ­Ha was the standard height, ΔH was the change inheight, A was (the number of specimens with or without
fracture at height Hi) + (the number of height changes), andN was the smaller number of specimens with or without

fracture. After conducting preliminary tests, the height waspredetermined to be 80 cm. Two-group comparisons wereconducted using the Student’s t-test. Statistical analyses
were performed using SAS version 9.2 (SAS Institute, Cary,
NC, USA). A p-value of < 0.05 was considered statisticallysignificant.

Results
Experiment 1: fixation at 0° of flexion and 13°of adduction
The ­PPFH50 values are listed in Table 2. The conditions
that were less likely to cause fracture were use of Ti, asmooth surface, and a thick cement mantle. No differences
between the CoCr and SUS stems were observed.

International Orthopaedics
Fig. 4  Use of the staircase
method for a representative
condition (standard condition
in experiment 1). The dottedline represents the calculated
periprosthetic fracture heightin 50% of the bone models.
The white and black circles
represent positive and negative
responses, respectively. Photographs showing all the broken
specimens

Table 2  PPFH50 at 0°of flexion and 13° of adduction

Table 3  PPFH50 at 10°of flexion and 0° of adduction

Conditions

PPFH50 (cm)Conditions

PPFH50 (cm)

Cobalt–chromium–molybdenum alloy: Standard
condition
Stainless steel alloy
Titanium alloy
Smooth surface
Thick cement mantle

61 ± 11

Cobalt–chromium–molybdenum alloy: Standard
condition
Stainless steel alloy
Titanium alloy
Smooth surface
Thick cement mantle

77 ± 560 ± 13Over 110108 ± 49
78 ± 1285 ± 990 ± 289 ± 581 ± 11

Data are presented as mean ± standard deviation

Data are presented as mean ± standard deviation

PPFH50 periprosthetic fracture height in 50% of the bone models

PPFH50 periprosthetic fracture height in 50% of the bone models

Experiment 2: fixation at 10° of flexion and 0°of adduction(7/7) at the proximal and distal sites, respectively (p < 0.05;
Fig. 5b).

The ­PPFH50 values are listed in Table 3. The conditions thatwere less likely to cause fracture were use of Ti and SUS, asmooth surface, and a thick cement mantle. The taper-slip
stems made of CoCr tended to fracture.

Fracture site characteristics
The fracture rates of the polished-surface stems were 78.6
(11/14) and 35.7% (5/14) at the proximal and distal sites,
respectively (p < 0.05; Fig. 5a). In contrast, the fracture
rates of the smooth-surface stems were 14.2 (1/7) and 100%

Discussion
Although the incidence of PPF of cemented femoral stems
is lower than that of uncemented femoral stems, a high failure rate is observed because of collarless, polished, tapered,and cemented stems [2–9]. Cemented stems have classically
been categorised into two types based on the differences inthe shear forces at the interface [10]. The PPF of cemented
stems is likely caused by the material and surface roughnessof the stems.

International Orthopaedics

Fig. 5  Photographs of representative cases showing the fracture sites.
a Proximal vertical fracture (standard condition; polished surface;drop height, 80 cm). b Distal transverse fracture (smooth surface condition; drop height, 100 cm)

Three materials are commonly used for synthesis of
cemented stems: CoCr, SUS, and Ti. Taper-slip stems
made of Ti are not favoured because they are associatedwith early failure and have two disadvantages: a stiffnessof approximately 50% compared to that for CoCr and SUS
stems and the susceptibility of the material to crevice corrosion [17]. Conversely, CoCr and SUS are considered tobehave similarly because they have similar Young’s modulus and Poisson’s coefficient values. However, Tsuda concluded that CoCr and SUS showed different mechanicalbehaviours within the bone cement, and that this difference
could be caused by a difference between surface wettability of the two materials [18]. Subsequently, Kaneuji et al.
performed dynamic loading tests on SUS and CoCr stems
and observed differences in subsidence and force at thebone–cement interface [14]. Moreover, Takegami et al.
performed a compression–torsion test and observed thatuse of CoCr stem, polished surface, acute-square proximal
form, and absence of a collar might be related to PPF [19].
Furthermore, Hirata et al. showed that CoCr had a lower
surface wettability than SUS, and CoCr did not adhere to
the bone cement; moreover, the surface roughness (Ra)of CoCr was 0.06 μm, and thus, the frictional coefficientof CoCr was lower than that of SUS [13]. The authors
concluded that for CoCr stems, a low adhesive effect anda low frictional coefficient may result in excessive taperslip. In the current study, use of Ti, and probably SUS,

were associated with a low risk of fractures; however,
the material-of-the-stem factor was inseparable from thesurface-roughness factor.
Regarding the surface roughness of the stems, compositebeam implants generally have a “satin” or “matte” surface
finish that maximises the mechanical strength of the cement
mantle–stem bond, whereas the taper-slip stem is designed
based on a dual- or triple-tapered stem geometry and typically has a “smooth” or “polished” surface finish, and thus,
the implant is able to wedge into the cement mantle [20].
Among Ti-cemented stems, composite-beam stems withsmooth surfaces result in excellent outcomes both in vivo
and in vitro, although the low elastic modulus of the titanium
alloy results in excessive stress on the proximal cement mantle, leading to micromovement and stem–cement debonding[21–23]. Our data also demonstrated that smooth surfaces
prevented fractures, and the clinically low incidence of PPFs
of composite-beam stems may be related to surface roughness. In addition, proximal vertical fractures were significantly more common in the polished-surface stems, whereas
distal transverse fractures were significantly more common
in the smooth-surface stems. This difference may be because
the smooth-surface stem behaved similarly to a composite
beam stem.
Clinically, there is a certain number of intraoperative
cracks, although the incidence of PPF in cemented stems is
low [3]. Some cracks may go undiagnosed because they are
not directly visible, especially if the approach is limited orif they occur on the posterior surface of the femur during ananterior approach [24]. This study suggests that proximal
cracks potentially exist and can propagate if not detected anddiagnosed intraoperatively.
Our study has some limitations. First, to assess the conditions resulting in PPF of taper-slip stems, ­PPFH50 was calculated using the staircase method. This method is a widelyused statistical fatigue test, which provides highly accurate
results; however, the accuracy of the standard deviation may
be low [25, 26]. Second, the falling-weight impact test was
not a cyclical loading test but a one-shot dynamic loading
test. In addition, the falling-weight impact test could not be
used to accurately assess the torque required for fracturingbones, although the flexure of the simulated bone was considered while performing Experiment 2. Third, the absenceof radiographs prevented us from determining the exact position of the femoral stem, particularly concerning the risk of
distal fractures [27, 28]. Fourth, this was a biomechanicalstudy; therefore, the results may differ from those obtainedin clinical practice. Although the conditions that cause PPF
of taper-slip stems were replicated using the falling-weight
impact test, PPF could be clinically caused by a variety offactors. Furthermore, fractures on cemented prostheses may
occur in the long term due to osteolysis or osteoporosis,
which can weaken the bone over time. Therefore, this study

International Orthopaedics

only addresses the risk of traumatic fracture of a cemented
prosthesis.
5.

Conclusions
Falling-weight impact tests demonstrated that a polishedtaper-slip stem made of CoCr with a thin cement mantle
may be associated with a high risk of PPF. Additionally,
proximal vertical fractures were significantly more common
in the polished-surface stems.
Acknowledgements This research did not receive any specific grants
from funding agencies in the public, commercial, or not-for-profit sectors. This study was supported by a provision of implant samples andsimulated bones from KYOCERA Co. The authors would like to thankTadaaki Shimeno, Takafumi Irie, Ryoma Hakumoto, Yuichi Hashimoto, Kazuo Teshi and Kiwamu Teshima. The authors are also obliged
to Tomomi Oe for the supervisor, and all stuffs involving this study.
Author contribution All authors contributed to the study conception
and design. Material preparation, data collection and analysis were
performed by Takuma Yagura, Kenichi Oe, Fumito Kobayasi, Shohei
Sogawa, Tomohisa Nakamura, Hirokazu Iida and Takanori Saito. The
first draft of the manuscript was written by Takuma Yagura and all
authors commented on previous versions of the manuscript. All authors
read and approved the final manuscript.
Data availability The data that support the findings of this study areavailable on request from the corresponding author (KO).

6.

7.

8.

9.

10.

Declarations

11.

Ethics approval The study design was not approved by the appropriate ethics review board because of no research involving human andanimal subjects.

12.

Consent to participate Not applicable.
Consent to publish Not applicable.

13.

Conflict of interest The authors declare no competing interests.

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