Abstract
Background
Periprosthetic femur fractures (PFFs) are challenging complications following total joint arthroplasty. Locking compression plates have emerged as a preferred option because of their stability and ability to be placed in a minimally invasive fashion. Surgical techniques for their application have been well-described; however, there are limited reports of failure. Here, we present 6 unique cases of implant failure using the Noncontact Bridging (NCB) Periprosthetic Plating System in the management of PFF.
Methods
A retrospective chart review was conducted of all open reduction internal fixation procedures using the NCB plating system for PFF performed at a single tertiary academic trauma center from 2015 to 2022. Instances of postoperative implant failure were selected for review. Surgical information regarding their index PPF and subsequent open reduction internal fixations were collected.
Results
Of the 44 instances the NCB plating system was used, 6 (13.6%) cases of implant failure were identified. Four out of 6 cases occurred within 4 months of fixation. Five of the failures were due to plate fracture and 1 by plastic deformation. Failure of the plate was noted at the tip of the prosthesis in 5 out of 6 cases. Stress concentration was minimized by avoiding the use of 3 consecutive screw plate holes in all cases.
Conclusions
Here we present the largest case series to date of NCB plating system failure. These cases highlight the need for further surveillance of plate failure in the management of PFF, as well as ways in which system design could be improved.
Level of Evidence
IV.
Keywords: Periprosthetic fracture, Open reduction internal fixation, Total joint arthroplasty, Periprosthetic plating, Revision arthroplasty
Introduction
Periprosthetic femur fractures (PFFs) are among the most challenging complications following total joint arthroplasty. They often occur in patients with multiple comorbidities and poor bone quality. With a rising number of elderly patients undergoing total joint arthroplasty, the incidence of PFF is increasing [1,2]. Locking compression plates have emerged as a popular treatment option because of their excellent stability and ability to be placed in a minimally invasive fashion [3,4]. A recent advancement in locking plate design is variable angle (polyaxial) locking with angular stability, enabling bicortical fixation while avoiding intramedullary prostheses. Surgical technique for polyaxial locking plates has been well-described [[5], [6], [7], [8]]; however, there are limited reports of failure in the literature. We present 6 cases of implant failure using the Non-contact Periprosthetic Plating System in the management of PFF.
Material and methods
This study was approved by our institution’s Research Ethics Board. All patients undergoing open reduction internal fixation (ORIF) with the Noncontact Bridging (NCB) periprosthetic plating system for PFF’s performed at a single tertiary academic trauma center between 2015 and 2022 were identified. Patients’ postoperative courses were retrospectively analyzed via institutional and provincial electronic health records. Cases involving mechanical failure of the NCB plating system were subsequently selected for review. Patient data recorded included patient age, body mass index (BMI), medical comorbidities, ambulatory status, and periprosthetic fracture type (described using the Vancouver classification) [9]. Surgical data recorded included index arthroplasty procedure, surgical approach, construct type of the revision ORIF procedures, time to and mechanism of plate failure, and latest known clinical status of the patient. Radiographs taken at the time of index PPF, initial ORIF, plate failure, and revision ORIF procedures were included. Anteroposterior and lateral views of full-length femur radiographs were collated using Adobe Illustrator.
Cohort characteristics
Of the 44 instances the NCB plating system was used, 6 (13.6%) cases of implant failure were identified. All 6 patients were women, and mean age and standard deviation was 82.7 ± 7.8 years. Mean BMI was 25.5 ± 5.6 kg/m2. Five cases were Vancouver B1 PPF’s, while 1 was Vancouver C. Four out of 6 cases occurred within 4 months of fixation. Two out of 6 cases were treated with submuscular plate fixation. Among the revision ORIF’s with NCB plating, 5 failures were due to plate fracture and 1 by plastic deformation.
In contrast, of the 38 (86.4%) patients who did not have an implant failure 31 (81.6%) were female. The mean age of this cohort was 83.2 ± 8.3 years, and the mean BMI was 24.8 ± 6.2 kg/m2. 29 patients had a Vancouver B1 fracture and 9 patients had a Vancouver C fracture. None of these variables were significantly different than the 6 patients who had an implant failure (P > .05).
Before revision ORIF, all patients were worked up for infection. All patients had a full infectious workup which included blood work including complete blood count, erythrocyte sedimentation rate, and C-reactive protein. They also had a metabolic workup which is standardized at our institution and includes calcium, vitamin D, testosterone when appropriate, thyroid stimulating hormone, albumin and other labs as we have previously published on for a nonunion management [10]. Intraoperative samples were cultured and were negative for infection. Appropriate postoperative fracture alignment, screw configuration, and construct rigidity were noted in all cases. Failure of the plate was noted at the tip of the prosthesis in 5 out of 6 cases. High stress concentration over a short plate length was minimized by avoiding the use of 3 screw plate holes in a row in all 6 cases. Locking caps were used for all screws in all instances of plate failure.
Case 1
A 96-year-old woman (BMI 22.8 kg/m2), who was a community ambulator with a walking frame, presented with a Vancouver B1 periprosthetic fracture [11] around a cemented bipolar hemiarthroplasty (Fig. 1a). Her medical history was significant for degenerative scoliosis, atrial fibrillation and hypertension. She was optimized for surgery and underwent ORIF via a lateral subvastus approach. Once adequate reduction was achieved, a 12-hole NCB Periprosthetic Proximal Femur Plate was placed with an anterior distal femur strut allograft to create a 90°–90° fixation construct. Three proximal peri-implant screws and 4 distal screws were augmented with 4 cerclage cables placed around the strut graft and plate using NCB Locking Plate Cable Buttons. Morselized cancellous allograft was placed at the fracture site and along the graft–host junction (Fig. 1b and c). The patient was discharged on postoperative day 6 and underwent rehabilitation from partial to full weight-bearing (FWB) over 6 weeks. Approximately 5 months after surgery, the patient reported increasing pain in her thigh without any trauma and radiographs revealed nonunion with plate fracture (Fig. 1d). After implant removal and thorough debridement, the fracture was stabilized with a 4.5 mm lateral femur limited contact dynamic compression plate (DePuy Synthes, Paoli, PA) combined with a medial tibial strut allograft. Several of the plate screws were secured into the allograft and fixation was augmented with 5 cerclage cables around both the plate and graft. Additionally, cancellous allograft mixed with bone morphogenetic protein (BMP) (INFUSE Bone Graft, Medtronic, Memphis, TN) was added to the nonunion and graft–host junction (Fig. 1e). At latest follow-up 4 years following revision ORIF, the patient was mobilizing independently with a walker and radiographs demonstrated fracture consolidation.
Figure 1.
(a) AP radiograph demonstrating a displaced periprosthetic fracture around a stable, cemented bipolar hemiarthroplasty in a 96-year-old female patient. (b) and (c) AP and lateral radiographs of the initial ORIF performed with NCB plating, an anterior distal femur strut allograft, screws, cerclage cables, and morselized cancellous allograft. (d) Subsequent nonunion with plate fracture. (e) Revision ORIF with an limited contact dynamic compression plate, a medial tibial strut allograft, and cerclage cables. AP, anteroposterior.
Case 2
A 76-year-old woman (BMI 35.4 kg/m2) who was an independent ambulator presented with a Vancouver B1 periprosthetic fracture following a mechanical fall (Fig. 2a). Her medical history was significant for osteoporosis, Type 2 diabetes mellitus and chronic obstructive pulmonary disease. Three days later, the patient underwent surgery. After achieving adequate reduction of the fracture through indirect techniques, a limited subvastus approach was performed and a 15-hole NCB Proximal Femur Periprosthetic Plate was placed submuscularly. Three unicortical screws and 2 cerclage cables with NCB locking plate cable buttons were placed in the proximal segment and 5 screws were placed in percutaneous fashion in the distal segment (Fig. 2b). The patient underwent rehabilitation from partial to FWB over 6 weeks. Approximately 4 months later, the patient re-presented with sudden onset thigh pain without trauma and radiographs confirmed nonunion with plate failure (Fig. 2c). After all previous hardware was removed and the nonunion debrided, the fracture was stabilized with a stainless steel distal femoral locking plate (AxSOS TS, Stryker, Kalamazoo, MI) combined with an anterior distal femur strut allograft to achieve a 90°–90° fixation construct. Two proximal unicortical screws and 5 distal screws were augmented with 5 cerclage cables placed around the plate and strut graft. Cancellous allograft mixed with BMP was placed at the nonunion and along the graft–host junction (Fig. 2d and e). The patient was mobilized to toe-touch weight bearing for 6 weeks, then progressed to FWB. After 8 months, however, she presented with a 4-week history of worsening prodromal pain and difficulty ambulating. Radiographic evaluation revealed plate failure, varus deformity at the nonunion site and fracture of the anterior aspect of the strut allograft (Fig. 2f). However, callus formation was evident medially and the patient was able to mobilize to a reasonable degree with her fibrous union. Therefore, it was decided to defer operative intervention while her metabolic bone health was optimized. Five months later (approximately 13 months post revision surgery), the patient was re-evaluated and noted to have persistent and symptomatic nonunion, with optimized metabolic bone health. Therefore, revision ORIF was again performed. After implant removal and thorough debridement, the fracture was stabilized with a stainless steel 4.5 mm lateral femur limited contact dynamic compression plate (DePuy Synthes) combined with a medial proximal femur strut allograft. The previous anterior allograft was found to have fully consolidated so was left in situ. Several of the plate screws were anchored into the medial allograft and fixation was augmented with four cerclage cables around the plate and graft. Additionally, cancellous allograft mixed with BMP was added to the nonunion and the graft–host junction (Fig. 2g). At latest follow-up 2 years after the second revision ORIF, the patient was mobilizing independently without aids and radiographs demonstrated full fracture consolidation.
Figure 2.
(a) AP radiograph demonstrating a displaced periprosthetic fracture around a stable, noncemented THA in a 76-year-old female patient. (b) Initial ORIF with screws and cerclage cables with NCB locking plate cable buttons. (c) Subsequent nonunion with plate failure. (d) and (e) AP and lateral radiographs demonstrating revision ORIF with screws, cerclage cables, strut grafting, and cancellous allograft mixed with BMP. (f) Repeat plate failure with varus deformity. (g) Repeat revision ORIF with implant removal, thorough debridement, addition of plate screws, cerclage cables, and cancellous allograft mixed with BMP. AP, anteroposterior.
Case 3
A 72-year-old woman (BMI 25.2 kg/m2), who was an independent ambulator, presented with a Vancouver B1 periprosthetic fracture following a mechanical fall (Fig. 3a). Her medical history was significant for osteoporosis, Hashimoto’s thyroiditis and Takotsubu cardiomyopathy. She was optimized for surgery and 2 days later underwent ORIF via a limited subvastus approach. To facilitate fracture reduction, cement was removed from the distal segment before an 18-hole NCB Periprosthetic Distal Femur Plate was placed submuscularly. Proximal fixation was obtained via 3 peri-implant screws (1 bicortical, 2 unicortical) and 3 cerclage cables. Six screws were placed in a staggered fashion distally (Fig. 3b). She was limited to toe-touch weight bearing for 6 weeks and discharged to a rehabilitation unit on postoperative day 3. Approximately 4 months later, the patient presented with a 3-week history of worsening thigh pain and difficulty ambulating. Radiographic evaluation confirmed plate fracture with a hypertrophic nonunion (Fig. 3c). Two days later the patient underwent revision ORIF. After implant removal and thorough debridement, the fracture was stabilized with a stainless steel distal femoral locking plate (AxSOS TS, Stryker) combined with a medial femoral strut allograft. Several plate screws were secured into the medial allograft and fixation was augmented with 4 cerclage cables around both the plate and graft. Cancellous allograft and morselized autograft from the callus were mixed with BMP and packed around the nonunion site and graft–host junction (Fig. 3d). By 6 months, the patient was walking without aids. Approximately 2 years after her revision ORIF; however, the patient re-presented with pain and difficulty ambulating. Radiographs showed that although the periprosthetic fracture had healed, with good incorporation of the allograft, subsidence of the femoral stem had occurred (Fig. 3e). This was felt to be mechanical in nature due to fracture through the cement mantle and the associated removal of the distal portion of the cement mantle at her original ORIF. The patient was treated with revision total hip arthroplasty (THA), involving revision of both components (Fig. 3f). Intraoperative specimens did not show any growth. At latest follow-up, 4 months after revision THA, the patient was independently mobilizing without aids.
Figure 3.
(a) AP radiograph demonstrating a displaced periprosthetic fracture around a stable, cemented THA in a 72-year-old female patient. (b) Initial ORIF with an 18-hole NCB periprosthetic distal femur place, proximal peri-implant and distal screws, and cerclage cables. (c) Subsequent plate fracture with hypertrophic nonunion. (d) Revision ORIF postimplant removal and debridement, fracture stabilization with a distal femoral locking plate, medial femoral strut allograft, cerclage cables, and allograft mixed with BMP around the nonunion site and graft–host junction. (e) Subsequent subsidence of the femoral stem 2 years after revision ORIF. (f) Revision THA involving revision of both components. AP, anteroposterior.
Case 4
An 86-year-old woman (BMI 22.7 kg/m2) with a history of dementia presented with a Vancouver C periprosthetic fracture 3 weeks after primary THA (Fig. 4a). A nondisplaced calcar fracture noted intraoperatively had been managed with 2 prophylactic cables. The patient was mobilizing WBAT when she sustained a mechanical fall. Two days later, the patient underwent ORIF using a nail-plate construct via a lateral subvastus approach. Once the fracture was reduced with 2 cerclage cables, and a supracondylar nail (T2 SCN, Stryker) was passed and locked proximally and distally. An 18-hole NCB Periprosthetic Distal Femur Plate was then applied. Proximal fixation was achieved with 4 unicortical screws and 2 bicortical screws, 1 of which also passed through the nail. Distally, 1 unicortical screw was placed in the region of the SCN and 5 screws were placed into the condylar block (Fig. 4b). The patient was mobilized WBAT and discharged back to her rehabilitation unit. Unfortunately, she continued to suffer recurrent falls and 1 year after her revision presented with refracture of her femur and plate breakage (Fig. 4c). At revision ORIF 5 days later, the SCN was found to be stable and was left in situ with 1 distal interlocking screw. All remaining implants were removed and following thorough debridement, the fracture was stabilized with a stainless steel distal femoral locking plate (AxSOS TS, Stryker), augmented with a posterior 4.5 mm waisted compression plate (AxSOS, Stryker) and 5 cerclage cables (Fig. 4d and e). At latest follow-up, 3 months after revision ORIF, the patient was mobilizing WBAT with a walker and radiographs demonstrated fracture healing.
Figure 4.
(a) AP radiograph demonstrating a displaced spiral periprosthetic fracture distal to the prosthesis in a cemented THA in an 86-year-old female patient. (b) Initial ORIF with cerclage cables, a supracondylar nail locked proximally and distally, and an 18-hole NCB periprosthetic distal femur plate with screws. (c) Refracture of the femur with plate breakage. (d) and (e) AP and lateral radiographs demonstrating revision ORIF with stabilization of the fracture with a distal femoral locking plate augmented with a compression plate and cerclage cables. AP, anteroposterior.
Case 5
An 80-year-old woman (BMI 23.4 kg/m2) with multiple medical comorbidities, including treated Stage IIB lung cancer and critical lower limb ischemia, presented with a Vancouver B1 periprosthetic fracture following a mechanical fall (Fig. 5a). Primary THA, 18 months previously, had been complicated by septic loosening of the acetabular cup, necessitating single-stage revision of both components 6 months postoperatively. Of note, an iatrogenic cortical defect (10 cm × 2 cm) in the posterior aspect of the proximal femur during cement removal had been managed with strut allograft and cerclage cables. Following presentation with her periprosthetic fracture, the patient was optimized for surgery and 2 days later underwent ORIF via a lateral subvastus approach using an 18-hole NCB Periprosthetic Distal Femur Plate. Fixation was obtained with 4 proximal screws (2 unicortical, 2 bicortical) and 6 distal screws, augmented with 2 cerclage cables placed around the proximal femur and plate using NCB Locking Plate Cable Buttons (Fig. 5b). The patient was mobilized weightbearing as tolerated (WBAT) and was discharged to a rehabilitation unit. Approximately 3 months later, the patient felt a snap in her thigh while mobilizing with her walker. Radiographs confirmed plate failure with nonunion of the periprosthetic fracture (Fig. 5c). Two days later, she underwent revision ORIF with multiple plating. Following removal of the broken plate and cerclage cables, a thorough debridement was performed. The strut graft from her revision THA appeared well-incorporated and was left in situ. The fracture was stabilized with a stainless steel distal femoral locking plate (AxSOS TS, Stryker), augmented with 2 4.5 mm waisted compression plates (AxSOS, Stryker) placed anteriorly and posteriorly. BMP was also added to the nonunion site (Fig. 5d and e). Two of 7 intraoperative specimens grew organisms, and although these were suspected to represent laboratory contamination, the patient was treated with 3 months of antibiotics. At latest follow-up, 5 months after revision ORIF the patient was mobilizing WBAT with a cane and radiographs confirmed fracture consolidation.
Figure 5.
(a) AP radiograph demonstrating a displaced periprosthetic fracture around a stable, cemented THA in an 80-year old female patient. (b) Initial ORIF with an 18-hole NCB periprosthetic distal femur plates, screws and cerclage cables with NCB locking plate cable buttons. (c) Plate failure with nonunion of the periprosthetic fracture. (d) and (e) AP and lateral radiographs of revision ORIF with removal of the broken plate, a distal femoral locking plate, 2 compression plates, and BMP at the nonunion site. AP, anteroposterior.
Case 6
An 86-year-old woman (BMI 35.2 kg/m2), who was a community ambulator with a walking frame, presented with a Vancouver B1 interprosthetic fracture following a mechanical fall (Fig. 6a). Her medical history was significant for Von Willebrand Disease, lupus, Type 2 diabetes mellitus and chronic kidney disease. The patient underwent ORIF via a lateral subvastus approach. Three cerclage cables were used to reduce the fracture, and subsequently an 18-hole NCB Periprosthetic Distal Femur Plate was placed. Fixation was obtained via 6 screws proximally (4 unicortical, 2 bicortical) and 4 screws distally. Three bicortical screws were also passed across the fracture and a single cerclage cable was placed around the femur and plate using an NCB Locking Plate Cable Button (Fig. 6b). The patient was mobilized WBAT and discharged to a rehabilitation unit. Approximately 4 months later, the patient presented with a 3-week history of increasing thigh pain and was no longer able to weight bear. Imaging demonstrated nonunion with varus deformity of the plate with bending (Fig. 6c), and the next day she underwent revision ORIF. Following implant removal and thorough debridement, the fracture was stabilized with a stainless steel distal femoral locking plate (AxSOS TS, Stryker), augmented with a posterior 4.5 mm waisted compression plate (AxSOS, Stryker) and an anterior tibial strut allograft (Fig. 6d and e). Five cerclage cables were placed around the plate and strut graft. One of 5 tissue samples demonstrated a very light growth of Cutibacterium acnes and the patient was given an extended course of antibiotics. At latest follow-up, 3 months after revision ORIF, fracture healing was evident on radiographs and the patient was mobilizing WBAT with a walker.
Figure 6.
(a) AP radiograph demonstrating a displaced spiral periprosthetic fracture distal to the prosthesis in a cemented hemiarthroplasty in an 86-year old female patient. (b) Initial ORIF with an 18-hole NCB periprosthetic distal femur plate with cerclage cables, screws, and an NCB locking plate cable button. (c) Subsequent nonunion with varus deformity of the plate with bending. (d) and (e) AP and lateral radiographs demonstrating revision ORIF with implant removal, stabilization with a distal femoral locking plate, a compression plate, an anterior tibial strut allograft, and cerclage cables. AP, anteroposterior.
Discussion
The NCB Periprosthetic Plating System is a line of polyaxial locking plates designed for the femur. Manufactured from a Titanium-6Al-4V alloy, the system comprises a Proximal Femur Plate, a Distal Femur Plate and a Curved Femur Shaft Plate [8]. The Proximal and Distal Femur Plates are wider in the periprosthetic region and feature offset holes in a diagonal motif that may allow bicortical screw fixation around the prosthesis. The key innovation of the system is the potential for polyaxial locking up to an angle of 30° relative to the plate. Cortical or cancellous screws may be used to reduce the fracture before locking is achieved via frictional coupling with endcaps that are threaded into the plate holes. A radiolucent device enables minimally invasive plate application.
Although many PFF are successfully managed with the placement of a lateral locking plate, plate failure remains a limiting factor and warrants close investigation [12,13]. These presented cases all represent failure of the NCB Periprosthetic Plating System, 5 by plate fracture and 1 by varus deformity. The most likely cause of failure in our series was delayed bone healing with long-term cyclic loading leading to fatigue failure. In these demanding injuries, the time to bony union often exceeds 6 months [5] and the ultimate goal of the selected fixation construct is to maintain fracture and implant stability while healing occurs. Dual plating of such fractures has become more prevalent in the literature and at our institution. We do not have a full case series for publication of dual plating cases with this NCB plate at present [14].
In addition to biomechanical risk factors for implant failure such a prosthesis design, prior research has demonstrated the importance of perioperative medical optimization of arthroplasty patients in minimizing risk of periprosthetic fractures. [15,16] At our institution, a multidisciplinary fracture liaison service manages high-risk fracture patients to optimize bone health, manage bisphosphonate use, osteoporosis, and other associated metabolic disorders. Use of integrated medical teams such as our have been shown to help mitigate fracture risks in at-risk patients such as these. [17]
Several patient-related factors and technical errors have been identified as reasons for failure of lateral locking plates [7,12]. In a large retrospective study of 335 PPF, Ricci et al. [18] determined smoking, open fracture and short working length to be independent risk factors for plate failure. None of our patients had these specific risk factors and review of postoperative imaging confirmed appropriate fracture alignment, screw configuration and construct rigidity. In particular, in no instance were 3 screws placed in any of the diagonal 3-hole patterns which would have created a stress riser. In addition, care was taken to avoid a high concentration of stress over a short length of the plate with overly rigid fixation proximal and distal to the fracture. In the setting of periprosthetic fractures around femoral components, there is inevitably a high concentration of stress at the tip of the prosthesis and failure of the plate occurred at this location in 5 of 6 cases. Minimally invasive techniques are important elements of biological fixation, but are not always applicable due to fracture morphology [13]. Thus, in our series, only 2 patients were treated with submuscular plate fixation. One patient underwent revision THA 2.3 years after PFF, suggesting that stem stability may have been misinterpreted at both the index and revision ORIF.
Interestingly, 5 out of 6 cases of plate failure occurred in cemented femoral prostheses. Prior literature has shown that cemented femoral fixation can be protective against periprosthetic fracture by decreasing the long-term effects of stress shielding. [[19], [20], [21]] In Case 6, the combination of a retained uncemented femoral stem with plate fixation may have been predisposed the patient to subsequent plate failure. Wang et al. demonstrated that uncemented THA and PFF fixation constructs have lower overall stiffness that increase the mechanical strain on the fracture plate compared to cemented constructs. [22] While the sample size is too limited to determine an association in our case series, this research suggests that PFF fixation of Vancouver type B1 fractures using a plate may have a higher risk of failure in uncemented THAs.
A biomechanical study has shown the bending fatigue strength of NCB Proximal Femur Plate to be almost twice that of the 4.5 mm locking compression plates Curved Broad Plate (DePuy Synthes) [23] and to date, there have been limited reports of its failure in the literature. Pressmar et al. [24] reported on 11 revision surgeries out of 31 PFF treated with the NCB Distal Femur Plate with an implant failure rate of 20% (6/31). In a 1-year follow-up of 61 PFF managed with the NCB Distal Femur Plate, El-Zayat et al. [25] noted only 2 cases of plate breakage, occurring at 6 and 7 months after surgery due to nonunion. More recently, Stockwell et al. [26] reported 2 cases of implant failure in which a nonlocked screw fretted through the annular seating of the plate; however, plate fracture did not occur in either case. Nonetheless, the presence of 3 screw holes in row (which invariably is the site of plate failure) presents a potential site of weakness for this plate design.
Conclusions
The NCB Plating System has been recommended for periprosthetic fractures of the femur. The failures in our series may be the result of patient-related factors (poor bone quality and nonunion leading to repetitive loading) as well as surgeon error in 1 case (misinterpretation of stem stability). However, our cases are typical of the patients who sustain these complex injuries and each fixation was performed by a fellowship-trained trauma surgeon with extensive experience of locking plate technology. Of note, 4 of the 6 failures occurred within 4 months of fixation. Further surveillance for plate failure in the management of periprosthetic fractures is certainly indicated, as are potential considerations for improved plate design. For instance, given that the site of plate failure is consistently at the tip of the implant and given that screws are rarely needed in this location, consideration could be given to plates designed with less or no screw holes at this location to the strengthen that portion of the plate. Certainly, further research into the management of these complex fractures is warranted.
Conflicts of interest
Amit Atrey is on the Speakers bureau/paid presentations for, is a Paid consultant for, and receives Research support from Zimmer biomet, S&N and Biocomposites and Other financial or material support from Zimmer. Aaron Nauth is on the Speakers bureau/paid presentations for Stryker and Synthes; is a paid employee for Toronto Blue Jays; is a Paid consultant for Stryker; receives Research support from Stryker, Synthes, Zimmer, and Conmed Linvatec; receives Fellowship funding from Zimmer and Synthes; and is a Board member/committee appointments for the Basic Science Committee Orthopaedic Trauma Association. Amir Khoshbin is a paid consultant for Smith & Nephew. The other authors declare there are no conflicts of interest.
For full disclosure statements refer to https://doi.org/10.1016/j.artd.2025.101753.
CRediT authorship contribution statement
Michael R. Mercier: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. James M. Broderick: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Catherine S. Hibberd: Conceptualization, Methodology, Project administration, Resources, Supervision, Writing – review & editing. Shane P. Russell: Conceptualization, Data curation, Project administration, Writing – review & editing. Mansur M. Halai: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing. Amit Atrey: Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing. Aaron Nauth: Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing. Amir Khoshbin: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
Appendix A. Supplementary data
References
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