Mini-symposium: Whats new in hip replacement Basic principles

(vii) Current developments

in short stem femoral
implants for hip replacement
surgery

Implant design
Currently a number of metaphyseal implants have a straight stem
extending into the upper diaphysis. The question whether these
stems guide forces into the metaphysis or switch load distribution
towards the upper diaphyseal area has recently been discussed
in studies using dual-energy x-ray absorptiometry. Bone mineral
density was used as a parameter to evaluate bone redistribution
around the prosthesis.6,7 Condensation of bone at the distal part
of the proximal metaphysis and the proximal diaphysis indicates
that implants achieve early stability and durable biological fixation. However, radiological analysis implies that bone loading
might not be as physiological as expected. Kim et al. published
a report, which revealed 87% grade 2 stress shielding, and 13%
grade 3 loss at the calcar in a distal metaphyseal load bearing
stem at mean follow up of 8.8 years (Figure 1).8 Decking et al.
confirmed that a decrease in proximal femoral strain seen with
conventional hip prostheses corresponds well to the reduction of
bone density noted in clinical follow-up studies.9 These radiological findings might not indicate impairment of clinical outcome in
the intermediate term, nevertheless they demonstrate that there
is room for improvement in stem design.10
Proximal load transfer and the absence of distal stem fixation are essential prerequisites for the best performance of the
femoral bone after primary total hip replacement. A stem-less
prosthesis which loads both medial and lateral proximal femoral

Wolfram H Kluge

Abstract
Bone-saving hip arthroplasty using metaphyseal stems is gaining importance because the number of young patients is on the increase and
hip resurfacing is not always indicated. This article outlines the recent
developments in short stem hip replacement following the concept of
conservative hip implants. The individual decision for use of a particular
type of implant remains crucial because a stem for all indications does
not exist. Every patient requires thorough pre-operative planning. Short
metaphyseal stems attempt to bridge the gap between straight stem implant design and hip resurfacing. A modern femoral implant should spare
healthy femoral bone during implantation, load the neck and metaphysis in a near physiological way, construct a biomechanically favourable
offset without unduly lengthening the leg and favour less invasive soft
tissue handling during implantation.

Keywords bone sparing; conservative implant; less invasive; metaphyseal stem; physiological load

Introduction
This article outlines the recent developments in short stem
hip replacement which fulfil the concept of conservative hip
implants.1 Diaphyseal cancellous bone-saving hip arthroplasty
using metaphyseal stems is gaining importance because the number of young patients requiring hip surgery is on the increase and
hip resurfacing is not always indicated. Active bone growth into
structured bio-inert stem surfaces lined with or without hydroxyapatite/calciumphosphate generates safe long-term fixation even
in less favourable bone quality.24 Surgical technique and implant
characteristics are of paramount importance for superior results
in hip replacement surgery.5 Products new to the market take
time to find general acceptance. New biomechanical concepts
usually require a training period prior to first time use, otherwise future confidence in an implant may be compromised. On
the other hand, implants with problematic technology may well
make it impossible to achieve good and reproducible results.
Short stem hip implants are usually uncemented prosthetic
devices. It is important to realize that metaphyseal stems load in
defined proximal femoral structures thereby ensuring long-term
fixation.

Wolfram H Kluge MD is Consultant Orthopaedic Surgeon, Hon. Senior

Lecturer at the University of Leeds, UK.

ORTHOPAEDICS AND TRAUMA 23:1

Figure 1 Intermediate term follow up radiograph of a proximally coated

cementless femoral component. Note: calcar atrophy.

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Mini-symposium: Whats new in hip replacement Basic principles

implantation guide aligning itself in the proximal diaphyseal cavity. The Mayo Conservative Hip has shown good results in longterm studies.14 Small variations in positioning of this short stem
within the metaphysis can greatly influence the hip joint mechanism. The implant may be unsuitable when there is critically
poor cancellous bone quality and/or adverse cortical anatomy.
On the other hand, the Mayo Hip offers a medullary bone-sparing
solution in complex femoral deformity (Figure 3). The surgeon
should pay particular attention to appropriate individual offset
reconstruction.

flares not only requires less intramedullary bone to be removed

intraoperatively but also preserves proximal bone stock in the
longer term.11,12 Biomechanic assessment of cyclic motion in a
short stem prosthesis like the Proxima implant (Figure 2) can
produce similar results to clinically successful shaft implants. The
same is true for fracture occuring when load tested on cadaver
bone. The reduced system stiffness of a short stemmed implant
suggests better physiological load transfer. Sufficiently good
bone stock is required when implanting a short stem because
higher cyclic motion and migration were observed for femora
with poorer bone quality.
Santori et al. reported on clinical and radiological results of
a custom made ultra-short stem prothesis with proximal load
transfer. 1131 hips were followed up at five-years.13 The stem
design was based on a fully coated implant with pronounced
lateral flare. The implant provided effective initial stability which
remained over time and appeared to imitate the loading pattern
in the normal proximal femur.

The Thrust Plate prosesthis

The Thrust Plate prosthesis utilizes metaphyseal fixation to
transmit load forces of the hip directly onto the femoral neck.
Early follow up studies have demonstrated favourable outcomes;
larger studies have recently become available.15 Karatosun et
al. retrospectively evaluated 71 hips (follow up 2887 months,
patient age over 65 years) after Thrust Plate arthroplasty.16 The
overall revision rate was 8.4%. After a history of trauma was
excluded, the rate for loosening and technical errors decreased to
4.2%. Karatosun et al. put no age limit on the indication for use
of the prothesis. Buergi et al. reported radiological and clinical
outcomes of 102 third generation Thrust Plate prostheses with a
mean follow-up period of 58 months (implant survival according
to Kaplan-Meier 98% after 6 years) Figure 4.17
Fink et al. followed up the survival of 214 implants over
a period of at least five years.18 Failure rate was 7.0% (nine
aseptic and six septic loosening). The authors concluded that
a Thrust Plate implant should not be considered as an alternative to a stemmed endoprosthesis. Jacob et al. implanted 102
Thrust Plates. They state that through the implants ability to
load the medial cortex of the proximal femur, cortical bone in
this region can be preserved (survival rate 98%, mean follow
up 144 months).19 According to Angin et al. a comparative gait
analysis in patients with intramedullary stemmed prostheses
and Thrust Plate prostheses did not produce any remarkable
differences.20

Mayo Conservative Hip

Concepts for primary fixation offered by current metaphyseal
implants are based on a diversity of biomechanical theories.
Multi-point cortical fixation supported by cancellous bone compression is typically represented by the Mayo Conservative Hip
(Zimmer). The straight double taper leans on the calcar but does
not follow an individual calcarcurve. The implant tip acts like an

Metha prothesis
A recent report published by Lazovic provided data about the
short stemmed Metha prosthesis (Aesculap) in 150 cases.21 The
author pointed out that the shape of the proximal femur limits
the flexibility of implant positioning in short stems. Therefore,
he employed navigation in order to reconstruct a biomechanically correct offset and stem antetorsion with use of a modular
neck implant.
The Cut prothesis
The Cut prosthesis (ESKA IMPLANTS) can provide good clinical and radiological results, but has shown a higher loosening
rate compared with cementless standard stems. Ender et al.
reported on 123 Cut femoral neck prostheses (average patient
age 53 years) after a mean follow-up of five years.22 Thirteen of
the implants had been revised, seven because of aseptic loosening, three because of persisting thigh pain, one because of
immediate vertical migration, and two because of septic loosening. The authors concluded that the medium-term survival is
unsatisfactory although the surviving implants had a good clinical outcome.

Figure 2 Proxima reproduced by kind permission of DePuy.

ORTHOPAEDICS AND TRAUMA 23:1

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Mini-symposium: Whats new in hip replacement Basic principles

Figure 3 Mayo Conservative Hip (Zimmer). Reconstruction of a dysplastic right hip.

developed for patients with osteonecrosis involving a large volume

of the femoral head. McMinn described improved physiologic proximal loading for the implant compared to earlier designs of neckconserving implants. One-year radio-stereometric analysis showed
negligible migration and preservation of femoral neck density.26
The development of new implants, which address bone conservation, is often based on experience with clinically proven
implants.27 Some of the newer implants however use entirely new
concepts. The Silent Hip (DePuy International) for example is a
tapered press-fit implant fixed within the femoral neck without
contact to the lateral cortex. The implant is currently in the precommercial clinical phase. The developers report that it allows
for nearly physiological proximal femoral loading (Figure 5). A
pilot clinical and radiological investigation including 41 patients
revealed that distal migration of the Silent stem was within a 12
mm limit at 2 years, suggesting good stability of the prosthesis.

Stress analysis of various femoral neck implants revealed that

the Cigar prosthesis caused the most pronounced changes in
stress distribution at the lateral thrust plate around the bored out
hole.2325 Strain increase in the region of the osteotomy of up to
1440 m/m could be detected for the Cigar and up to 1000 m/m
for the Rip prosthesis. The stress pattern after implantation of the
Cut prosthesis remained similar to the pre-interventional femoral
stress distribution.
The Birmingham Mid Head Resection prosthesis
The Birmingham Mid Head Resection prosthesis (Smith and
Nephew Orthopaedics Ltd) is an uncemented short stem prothesis

Leg length and offset

Wilson remarked in his Report for the Committee for the Study of
Femoral-Head Replacement in 1954 that hip prostheses represent
a new method of substituting a metallic or plastic counterpart for
a portion of skeleton.28 He stated that prosthetic replacement, no
matter what kind, has been used too often without attention to
the principles and requirements for success in hip arthroplasty.
Wilson discussed one of the reasons for implant instability: shortness of the femoral implant neck, which resulted in a relaxed
unstable joint. His recommendation to solve this problem was
to place the stem in valgus and thereby lengthen the neck. Hip
surgeons have since discovered the vital importance to not only
adapt the implant neck length but also reconstruct the hip offset.
Leg length concerns following hip replacement have become a
major medico-legal problem.
Individual reconstruction of a biomechanically favourable offset is limited because many implants simply increase the offset
along with stem size. It is not recommended to ream the isthmus
of the femur in order to fit a bigger implant required by offset
considerations. On the other hand, a stem adequately sized to
create the appropriate offset might not descend far enough during implantation because of its bulky distal aspect. The latter
implant inevitably leads to leg lengthening.

Figure 4 Thrust Plate prosthesis.

ORTHOPAEDICS AND TRAUMA 23:1

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2008 Elsevier Ltd. All rights reserved.

Mini-symposium: Whats new in hip replacement Basic principles

Figure 5 Silent Hip. Reproduced by kind permission of DePuy

International.
Figure 6 Fitmore Hip (Zimmer).

There is not necessarily an association between the metaphyseal femoral anatomy and neck offset. A large neck offset might
present with a very narrow proximal femoral canal (Champagne
glass). One could argue that these patients are candidates for hip
resurfacing. Indeed this often appears to be the most appropriate
treatment option. However, indications for hip resurfacing are
limited. Despite promising reports, femoral head vascularity and
risks like femoral neck fracture/resorption should be considered
individually.2931
It appears a logical step to remove the defective femoral head
and replace it by an implant, which utilises the healthy femoral
neck and proximal metaphyseal area for fixation. On-growth to
the implant and strengthening of bone should be facilitated by
predictable tension/pressure distribution during weight-bearing.
The implant must allow for individual offsetreconstruction more
or less independent of the stem size avoiding damage to the proximal femoral diaphysis. Implant philosophy has evolved from
considering stem alignment in the direction of the diaphyseal
axis. Today developers regard it to be safe to fix the stem along
the metaphyseal curve. One major advantage of this concept is
preservation of the greater trochanter by implantation through
the femoral neck.
Recently a further metaphyseal stem concept has been introduced. The Fitmore Hip (Zimmer) focuses on reconstruction
of individual anatomy as accurately as possible. This anatomical
stem follows the metaphyseal curve along the calcar and facilitates less invasive surgery. The implant offers the widest range
of offsets independent of stem size. Promising initial results on
short-term follow up have been reported (Figure 6). 32

ORTHOPAEDICS AND TRAUMA 23:1

Practical considerations
Survival rates of metaphyseal prostheses currently appear to
be lower than for cementless standard stems. Nevertheless,
metaphyseal implants have the advantage of preserving proximal
femoral medullary bone without the need to disrupt the diaphyseal marrow cavity. Should a change of endoprosthesis become
unavoidable, a standard stem anchored in the proximal femur
can be utilized.33
In vitro studies of short-stemmed femoral implants have
shown more initial migration than for conventional stems. The
short implants stabilised when cortical contact was achieved
or cancellous bone was compacted sufficiently.34 Lower cyclic
motion of the short stems indicate better physiological loading
of the bone. Not only intra-operative destruction of the proximal
femur is comparatively small but also secondary bone remodelling around the ingrown implant appears closer to physiological
conditions.
Rasp alignment in short stems can be difficult, because guidance provided by the proximal diaphyseal cavity as in longer
stems, is missing. For implants with a shoulder, the surgeon
might have to open a gully into the cancellous greater trochanter. Otherwise, the implant deviates into varus position during
impaction with increased risk of a calcar crack or intra-operative
lateral femoral perforation.
Pre-operative analysis of a lateral hip film can be very helpful
in order to anticipate potential difficulties in stem implantation,
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Mini-symposium: Whats new in hip replacement Basic principles

particularly if the surgeon intends to do a high femoral neck

resection. Anteversion of the neck and the physiological proximal femoral bend with its apex towards the posterior metaphysis
complicate the initial orientation of the implant within the cancellous bone. The experienced surgeon will find the correct entry
point far enough posteriorly within the femoral neck osteotomy
in order to avoid mal-position, mainly when using a limited soft
tissue approach.
The decision about an individual indication for use of a particular type of implant remains crucial. A stem for all indications
does not exist and surgeons are asked to study the anatomy in
every case. Every patient requires thorough pre-operative planning. Medico-legal proceedings in relation to hip replacement
surgery are a constant reminder of our responsibilities about
implant choice and operative technique. As with any implant,
metaphyseal prostheses require special training for the first time
user in order to avoid potential pitfalls.

9 Decking R, Puhl W, Simon U, Claes LE. Changes in strain distribution

of loaded proximal femora caused by different types of cementless
femoral stems. Clin Biomech 2006; 21: 495501.
10 Karachalios T, Tsatsaronis C, Efraimis G, Papadelis P, Lyritis G,
Diakoumopoulos G. The long-term clinical relevance of calcar
atrophy caused by stress shielding in total hip arthroplasty: a
10-year, prospective, randomized study. J Arthroplasty 2004; 19:
469475.
11 Santori N, Albanese CV, Learmonth ID, Santori FS. Bone
preservation with a conservative metaphyseal loading implant. Hip
Int 2006; 16: 1621.
12 Westphal FM, Bishop N, Pueschel K, Morlock MM. Biomechanics of a
new short-stemmed uncemented hip prosthesis: an in-vitro study in
human bone. Hip Int 2006; 16: 2230.
13 Santori FS, Manili M, Fredella N, Tonci Ottieri, Santori N. Ultra-short
stem with proximal load transfer: clinical and radiographic results at
five-year follow-up. Hip Int 2006; 16: 3139.
14 Morrey BF, Adams RA, Kessler M. A conservative femoral
replacement for total hip arthroplasty. A prospective study. J Bone
Joint Surg 2000; 82-B: 952958.
15 Steens W, Rosenbaum D, Goetze C, Gosheger G, van den Daele R,
Steinbeck J. Clinical and functional outcome of the thrust plate
prosthesis: short- and medium-term results. Clin Biomech 2003; 18:
647654.
16 Karatosun V, Unver B, Gunal I. Hip arthroplasty with the thrust
plate prosthesis in patients of 65 years of age or older: 67 patients
followed 27 years. Arch Orthop Trauma Surg. 2007 Nov 6 [Epub
ahead of print].
17 Buergi ML, Stoffel KK, Jacob HA, Bereiter HH. Radiological findings
and clinical results of 102 thrust-plate femoral hip prostheses: a
follow-up of 2 to 8 years. J Arthroplasty 2005; 20: 108117.
18 Fink B, Wessel S, Deuretzbacher G, Protzen M, Ruther W. Midterm
results of thrust plate prosthesis. J Arthroplasty 2007; 22: 703710.
19 Jacob HA, Bereiter HH, Buergi ML. Design aspects and clinical
performance of the thrust plate hip prosthesis. Proc Inst Mech Eng
2007; 221: 2937.
20 Angin S, Karatosun V, Unver B, Gunal I. Gait assessment in patients
with thrust plate prosthesis and intramedullary stemmed prosthesis
implanted to each hip. Arch Orthop Trauma Surg 2007; 127: 9196.
21 Rapp SM. Surgeon finds navigation enhances his accuracy placing
short, modular hip stems. Orthopaedics Today International 2008;
11: 8.
22 Ender SA, Machner A, Pap G, Hubbe J, Grasshoff H, Neumann HW.
Cementless CUT femoral neck prosthesis: increased rate of aseptic
loosening after 5 years. Acta Orthop 2007; 78(5): 616621.
23 Wieners G, Pech M, Streitparth F, Jansson V, Plitz W. Photoelastic
stress analysis of human femurs before and after implantation of
different models of femur neck prostheses. Z Orthop Unfall 2007;
145: 8187.
24 Steinhauser E, Ellenrieder M, Gruber G, Busch R, Gradinger R,
Mittelmeier W. Influence on load transfer of different femoral neck
endoprostheses. Z Orthop Ihre Grenzgeb 2006; 144: 386393.
25 Hofmann D, Ecke H, Nietert M, Langhans M. Experimental study
supported by the German Research Society: stress at the proximal
femur after implantation of different cementless hip prostheses.
Langenbecks archives of surgery; Springer Berlin/Heidelberg: 1987
vol. 372, pp. 849.
26 McMinn DJW, Daniel J, Pradhan C. A vascular necrosis in the young
patient: a trilogy of arthroplasty options. Orthopedics 2005; 28: 945.

Conclusion
Short metaphyseal stems attempt to bridge the gap between
straight stem implant design and hip resurfacing. Technically a
modern femoral implant should: (A) spare healthy femoral bone
during implantation, (B) load the neck and metaphysis in a near
physiological way, (C) construct a biomechanically favourable
offset without unduly lengthening the leg and (D) favour less
invasive soft tissue handling during implantation.

References
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2 Teloken MA, Bissett G, Hozack WJ, Sharkey PF, Rothman RH. Ten
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cobalt-chromium femoral component (Tri-Lock) inserted without
cement. J Bone Joint Surg Am 2002; 84: 21402144.
3 Kim KI, Klein GR, Sleeper J, Dicker AP, Rothman RH, Parvizi J.
Uncemented total hip arthroplasty in patients with a history of
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4 Parvizi J, Sharkey PF, Hozack WJ, Orzoco F, Bissett GA, Rothman RH.
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uncoated femoral stems in total hip arthroplasty. A concise followup of a previous report. J Bone Joint Surg Am 2004; 86: 783786.
5 Hallan G, Lie SA, Furnes O, Engesaeter LB, Vollset SE, Havelin LI.
Medium- and long-term performance of 11 516 uncemented primary
femoral stems from the Norwegian arthroplasty register. J Bone Joint
Surg 2007; 89-B: 15741580.
6 Albanese CV, Rendine M, De Palma F, et al. Bone remodelling in
THA: a comparative DXA scan study between conventional implants
and a new stemless femoral component. a preliminary report.
Hip Int 2006; 16: 915.
7 Kulkarni M, Wylde V, Aspros D, Learmonth ID. Early clinical
experience with a metaphyseal loading implant: why have a stem?
Hip Int 2006; 16: 38.
8 Kim YH. The results of a proximally coated cementless femoral
component in total hip replacement: a five to 12 year follow-up.
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Mini-symposium: Whats new in hip replacement Basic principles

34 Westphal FM, Bishopa N, Honlb M, Hillec E, Pscheld K, Morlocka

MM. Migration and cyclic motion of a new short-stemmed hip
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27 Biomet launches hip technologies to address demand for minimally

invasive bone-conserving implants. Biomet, Inc. Warsaw, Indiana.
Also available at: http://www.biomet.com.
28 Wilson PD. Report of the Committee for the Study of Femoral-Head
Replacement. Symposium on Femoral-Head Replacement Prostheses:
based on the Prostheses as Printed in the October (1954) Issue of
the Bulletin. J Bone Joint Surg Am 1956; 38: 407420.
29 Amstutz HC, Beaul PE, Dorey FJ, Le Duff MJ, Campbell PA, Gruen
TA. Metal-on-metal hybrid surface arthroplasty: two to six-year
follow-up study. J Bone Joint Surg Am 2004; 86: 2839.
30 Steffen RT, Pandit HP, Palan J, et al. The five-year results of the
Birmingham hip resurfacing arthroplasty. J Bone Joint Surg 2008;
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31 Mont MA, Seyler TM, Plate JF, Delanois RE, Parvizi J. Uncemented
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33 Stukenborg-Colsman C. Femoral neck prostheses. Orthopade 2007;
36: 347352.

ORTHOPAEDICS AND TRAUMA 23:1

Practice points
Pre-operative planning is essential in order to avoid malposition of the metaphyseal implant
The surgeon should find the correct entry point far enough
posteriorly within the femoral neck osteotomy mainly when
using a limited soft tissue approach
Short implants achieve best primary stability when cortical
contact is achieved and cancellous bone is compacted
sufficiently
Should exchange of the metaphyseal stem become necessary, a
standard stem anchored in the proximal femur can be utilized

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2008 Elsevier Ltd. All rights reserved.