Archives of Orthopaedic and Trauma Surgery - 2026-03-30 - Journal Article
Extra-long femoral heads as a surrogate marker for revision risk in primary total hip arthroplasty.
Beckers G, Simon D, Grimberg A, Wu Y, Steinbrück A, Holzapfel BM
Topics
Key Takeaway
Extra-long (≥XL) femoral heads in primary THA are associated with a 7.2% vs. 4.5% cumulative 9-year revision rate compared to standard heads, with use inversely correlated with hospital volume (5.4% low-volume vs. 3.0% high-volume centers).
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Summary
This study used the German Arthroplasty Registry to identify factors associated with ≥XL femoral head use and its impact on implant survival across 562,001 primary THAs. Logistic regression identified male sex (OR 2.13), FNF indication (OR 1.92), BMI ≥40 (OR 1.94), cemented fixation (OR 1.14), and low hospital volume (OR 0.56 for high-volume) as independent predictors of ≥XL head use. Kaplan–Meier analysis demonstrated 7.2% vs. 4.5% cumulative revision rates at 9 years for ≥XL vs. standard heads, consistent across all volume, indication, and fixation subgroups.
Key Limitation
The registry lacks component-level data on taper junction design, head material, and stem offset options, making it impossible to determine whether revision risk is driven by taper corrosion, residual biomechanical imbalance, or case complexity independent of head length choice.
Original Abstract
AIMS
The effect of femoral head length on implant survival in total hip arthroplasty (THA) has been little studied so far. Longer heads may increase taper corrosion and reflect intraoperative complexity. This study evaluated factors associated with the use of extra-long heads (≥ XL) and their impact on implant survival.
METHODS
We analyzed 562,001 primary THA from the German Arthroplasty Registry. Subgroup analyses were performed by hospital annual primary THA volume (≤ 250, 251–500, ≥ 501), surgical indication (primary osteoarthritis [OA] vs. femoral neck fracture [FNF]), and fixation method (cemented vs. cementless). Logistic regression identified factors associated with ≥ XL head use, and implant survival was compared between head lengths using Kaplan–Meier analysis in both subgroups and the overall cohort.
RESULTS
The use of ≥ XL femoral heads decreased with increasing hospital volume (5.4% low, 4.5% medium, 3.0% high; p < 0.001). Rates were higher in FNF than OA across all volumes (8.1% vs. 4.7% in low-volume hospitals; 5.0% vs. 2.7% in high-volume hospitals). Cemented fixation was independently associated with higher odds of ≥ XL head use (OR 1.14, 95% CI 1.09–1.18, p < 0.001), with additional predictors including male sex (OR 2.13, 95% CI 2.06–2.19), BMI ≥ 40 (OR 1.94, 95% CI 1.77–2.12), higher Elixhauser comorbidity score (OR 1.09, 95% CI 1.04–1.15), and surgery for FNF (OR 1.92, 95% CI 1.83–2.02), while treatment at high-volume hospitals was associated with lower odds (OR 0.56, 95% CI 0.54–0.58). Kaplan–Meier analysis revealed higher cumulative revision rates with ≥ XL heads (7.2% vs. 4.5% at 9 years), consistent across all subgroups.
CONCLUSION
The use of femoral heads ≥ XL was independently associated with lower hospital THA volume, femoral neck fracture, cemented fixation, male sex, higher BMI, and greater comorbidity burden. Their implantation was also linked to higher revision rates, suggesting that ≥ XL heads may serve as a surrogate marker for increased revision risk after primary THA.