Journal of Orthopaedic Science xxx (2015) 1e4

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Journal of Orthopaedic Science

journal homepage: http://www.elsevier.com/locate/jos

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
a
Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Hong Kong
b
Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hong Kong

a r t i c l e i n f o

Article history:
Received 29 July 2014
Received in revised form
30 January 2015
Accepted 15 February 2015
Available online xxx
1. Introduction
The Exeter femoral stem was in clinical use since 1970 with good
result [1]. The collarless, double tapered, polished design allows
controlled subsidence of the femoral stem within the cement
mantle. Adequate thickness of cement mantle is critical for the
long-term success of Exeter femoral stem. However, the original
design was aimed for Western population and stem oversizing was
common in Asian population with small body build [2e4]. Smaller
Asian size Exeter femoral stem was introduced to fit the Asian
population. Smaller Asian size stems with 30 mm and 33 mm offset
have been made available since 1998. In view of the small size of
the Asian stem, stem fracture is of concern.
Here we report a case of Asian size Exeter femoral stem fracture.
Factors contributed to the stem fracture were discussed. Careful
pre-operative planning and meticulous surgical technique should
be employed when use of small stem. Biomechanical studies to
define the weight limitation for the smaller Asian size Exeter
femoral stem was recommended. The patient was informed that
data concerning the case would be submitted for publication, and
she consented.
2. Case report
A lady suffered from bilateral hip dysplasia underwent bilateral
total hip arthroplasties. The right total hip arthroplasty was
* Corresponding author. Department of Orthopaedics and Traumatology, Prince
of Wales Hospital, Shatin, Hong Kong. Tel.: þ852 2632 2901; fax: þ852 2637 7889.
E-mail address: kychung@ort.cuhk.edu.hk (K.-Y. Chung).
performed at the age of 70 and the left total hip arthroplasty was
performed at the age of 72. She weighed 71 kg at the time of right
total hip arthroplasty and weighed 78 kg at the time of left total hip
arthroplasty. The fixations of both hip arthroplasty were in hybrid
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-
grade filling and pressurization was used in both hips. Intra-
operatively, the femoral stems were well supported by cement
mantle proximal medially. Post-operatively, there was no pain over
both hips. She lived a sedentary lifestyle and could walk with one
cane for 20 min. The Harris hip score for the right hip improved
from 26 to 81 after the operation [5]. The Harris hip score for the
left hip improved from 26 to 83 after the operation. Early post-
operative plain radiograph revealed the cement mantle was
Barrack grade B in both hips [6]. The right femoral stem was in 3

varus alignment and the left femoral stem was in neutral alignment
(Fig. 1). The right acetabular cup was in relatively lateralized posi-
tion. Lateral plain radiograph of the right hip showed adequate
cement mantle of more than 2 mm in all zones (Fig. 2).
She experienced sudden onset of right proximal thigh pain six
years after the index operation. There was no history of trauma. The
pain was mechanical, and affected her ambulatory ability. She could
only walk with frame for five minutes since she experienced the
symptom. Physical examination revealed her body weight was
78 kg with body mass index of 31.6. There was diffuse focal
tenderness over right proximal thigh. There was no sign of focal
infection. Pain over right proximal thigh was elicited upon flexion
and rotation of right hip. Plasma white cell count and C-reactive
protein were normal. Bone mineral density was not measured.
Plain radiograph revealed fracture at the junction of proximal one-
third and distal two-third of the Exeter stem and there was fracture
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
was noted. The medial calcar bone was intact. The proximal part of
the fractured stem was easily retrieved, but the distal part was well

http://dx.doi.org/10.1016/j.jos.2015.06.016
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://
dx.doi.org/10.1016/j.jos.2015.06.016
2 K.-Y. Chung et al. / Journal of Orthopaedic Science xxx (2015) 1e4
Fig. 1. Radiograph showing bilateral total hip arthroplasties.
fixed within the cement mantle. Extended trochanteric osteotomy
was required to retrieve the distal part of the fractured stem.
Femoral stem was revised using long stemmed extensively coated
cementless Solution stem (DePuy, Warsaw, IN). The extended
trochanteric osteotomy was repaired with cable wires (Fig. 4). She
was put on touchdown walking exercise for six weeks, followed by
Fig. 2. Lateral radiograph showing the right total hip arthroplasty.
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://
dx.doi.org/10.1016/j.jos.2015.06.016
Fig. 3. Radiograph showing right femoral stem fracture.
partial weight bear walking exercise for six weeks, followed by
weight bearing as tolerated. She recovered well after the revision
surgery. The Harris hip score for the right hip was 81 at 3.5 years
after the revision surgery. The left total hip arthroplasty was
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. 4. Radiograph showing revision right total hip arthroplasty.
 K.-Y. Chung et al. / Journal of Orthopaedic Science xxx (2015) 1e4
noted in this initial design. Eight of 426 (1.87%) Exeter stems
implanted from 1970 to 1976 fractured at an average follow up of 13
years [1], which increased to 3% of the original cohort with a
minimum follow up of 20 years [7]. Due to this unexpected high
failure rate, the stem was modified to matte surface and stronger
stem with larger anteroposterior diameter in 1976. Stem fracture
dramatically dropped to 0.03% (one in 2968 stems) with this
modified stem [1], and reported to be 0.22% in the latest available
report [7]. Though, in contrary, a high fracture rate of 11% (three in
27 stems) with this modified stem was reported by Røkkum [8].
However, extensive burnishing on the matte surface due to metal
and cement debris production by fretting during stem subsidence,
leading to increased osteolysis and subsequent aseptic loosening.
As a result, polished surface was reintroduced in 1986 and a high
strength, low corrosion stainless steel (Orthinox) with fatigue
properties similar to forged high strength vitallium was used as the
material of the stem. The stem fracture rate of this new design was
extremely low [9e11].
The use of aforementioned high nitrogen stainless steel in the
modern cemented femoral stem aimed at elimination of stem
failure. However, cases of stem fracture were still observed. Yates
reported 14 cases of fracture with stem made of high nitrogen
stainless steel by three different manufacturers, of which 12 were
fractured within the cement mantle [12]. Fractures of the femoral
stem have been studied and contributing factors were identified
[12e15], including (1) high stress in stem due to overweight, un-
dersized prosthesis or high level of activity; (2) poor proximal bone
support or fixation, which may be due to absence of calcar; (3)
varus orientation of the stem; (4) cantilever bending of the stem
resulting from good distal fixation but inadequate proximal cement
mantle; and (5) material defects in the stem itself. One or a com-
bination of the above contributing factors leads to the catastrophic
failure of the stem in both the early generation, and the newer
implant as reported by Yates [12]. Apart from Yates' report, Raj and
van Doorn also reported their isolated case of modern cemented
stem fracture in primary and revision total hip arthroplasty with
impaction allografting respectively [16,17].
Stem with similar design and subsidence principle made of co-
balt chrome were manufactured. They are stronger, but are not
immune from fracture. Jazrawi published the only report of two
cases fracture of collarless, tapered, polished cemented cobalt
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://
dx.doi.org/10.1016/j.jos.2015.06.016
3
chrome stem with the above mentioned risk factors, both of which
are revision arthroplasties [15]. Though other authors experienced
cobalt chrome stem fracture with a different design and fixation
principle [18,19].
Chiu published the result of Exeter total hip arthroplasty in
Chinese patients [2e4]. Small body build, and thus small size femur
with stem oversizing were common with the Exeter stem originally
designed for Western population. Oversizing of the stem and
incomplete or inadequate cement mantle might account for the
early loosening. Among 27 stems considered oversized with inad-
equate or incomplete cement mantle, the failure rate was 22.2%,
while none of those with adequate cement mantle failed [3]. In
those 27 oversized stem, smallest size stem in the study period
were used in 18 hips. 35.5 mm offset Exeter stem have been in use
since 1997 and two smaller stems with 30 mm and 33 mm offset
(Fig. 5) have been made available to this population since 1998. In
the subsequent 5 years following its availability, CDH or smaller
stems were used in 73.2% of Exeter total hip arthroplasties [3]. No
stem failure was observed at the time of Chiu's reporting [3,4].
Fujita [20], Sivananthan [21], and Tai [22] from different Asian
centers also reported their results of small Exeter stem implanted
for primary and revision total hip arthroplasties, with no stem
fracture observed. Choy compared the results of Exeter short stems
with the standard length Exeter stems from the national joint
replacement registry [23]. One small stem fracture was mentioned,
but detail on the cause of failure was not available. Stem fracture is
a rare event. The rate of small stem fracture in this large series was
0.066%, and the rate of standard stem fracture was 0.029% [23]. To
our knowledge, this is the first report of fracture of Asian size Exeter
stem with detail discussion.
In the present report, the acetabular cup was in relatively lat-
eralized position. The proximal cement mantle in the failed stem
was noted to be more than 2 mm during the revision surgery. The
stem was placed in 3
varus, which increased the bending moment
and tensile stress on the implant, might contribute to the fracture.
More meticulous removal of cancellous bone over proximal lateral
femur would allow insertion of stem in neutral alignment and
possibly larger 35.5 mm offset stem. Moreover, the stem was
inserted to the distal reference marking and femoral head with
additional 5 mm length was implanted. Though within the
recommendation of the manufacturer, both contributed to the
4 K.-Y. Chung et al. / Journal of Orthopaedic Science xxx (2015) 1e4
increase in offset and thus bending moment. In addition, a relative
small 33 mm offset stem was implanted into a patient weighed
71 kg, and subsequently her weight increased to 78 kg, with a body
mass index of 31.6. Though there was no weight restriction posed
by the manufacturer, we feel that this could be a contributing factor
to the stem fracture. A combination of the above factors resulted in
the catastrophic failure of the small stem in the present report.
Extended trochanteric osteotomy was performed to facilitate
retrieval of the distal part of the fractured stem and removal of
cement mantle. However, a period of protected weight bear
walking was required after the osteotomy. Also, there are risks of
fracture of osteotomy fragment, migration of the osteotomy frag-
ment, Trendelenburg's gait, non-union and trochanteric pain [24].
Careful consideration should be made during pre-operative
planning when use of small stem in overweight patient is antici-
pated. Cementless stem fixation, which allows larger implant, and
stem with modularity between proximal and distal part, which
allows better matching in champagne glass shaped canal, are
possible alternatives. Special attention to technical details during
stem insertion is also critical for the long-term success of small
stem. Appropriate removal of cancellous bone allows proper posi-
tioning of the stem in coronal and possibly sagittal plane; and
aggressive removal of cancellous bone to reach the stronger para-
cortical bone allows accommodation of larger stems without
compromising the cement mantle [12]. Insertion of stem to
appropriate depth and avoid the use of femoral head that increased
the offset while maintaining adequate soft tissue tension are also
critical. Substitution of stainless steel stem with cobalt chrome
stem may also play a role, due to its higher fatigue strength.
Currently, there are reports of fracture of cobalt chrome stem
designed for Exeter principle used in revision arthroplasties and
fracture of cobalt chrome stem with different design and fixation
principle, but there is no fracture of cobalt chrome stem designed
for Exeter principle used in primary total hip arthroplasty reported
in literature [15,18,19]. We also recommend the manufacturer to
perform biomechanical studies on the smaller Asian size Exeter
stem and recommend the body weight limitation which the small
stem can tolerate.
Conflict of interest
The authors declare that they have no conflict of interest.
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