Orthopedics

The Cutting Edge 

Outcomes of Short Stems in Total Hip Arthroplasty

Samik Banerjee, MD; Robert Pivec, MD; Kimona Issa, MD; Steven F. Harwin, MD; Michael A. Mont, MD; Harpal S. Khanuja, MD

Abstract

Short-stem total hip arthroplasty has been proposed as a bone-conserving procedure for the younger and more active population undergoing total hip arthroplasty. Although various short stems are currently available, no studies compare the outcomes between these stems. The aim of the current study was to conduct a systematic review of the clinical and radiographic outcomes of the various short stems that have been approved for use in the United States by the Food and Drug Administration. Outcomes that were assessed included implant survivorship, Harris Hip scores, thigh pain, periprosthetic fracture, subsidence, proximal stress shielding, and the prevalence of stem malalignment and inappropriate implant sizing.

The authors are from the Rubin Institute for Advanced Orthopedics (SB, RP, KI, MAM, HSK), Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland; and the Department of Orthopaedic Surgery (SFH), Beth Israel Medical Center, New York, New York.

Drs Banerjee, Pivec, and Issa have no relevant financial relationships to disclose. Dr Harwin receives royalties from Stryker and SLACK Incorporated; is on Speaker’s Bureau for Stryker and Convatec; is a paid consultant for Stryker and Convatec; has stock or stock options in Stryker; and is on the editorial or governing board for the Journal of Arthroplasty, Orthopedics, Journal of Knee Surgery, and Surgical Technology International. Dr Mont receives royalties from Stryker and Wright Medical Technology, Inc; is a paid consultant for Biocomposites and TissueGene; and has received research support from DJ Orthopaedics. Dr Khanuja is a paid consultant for Ethicon and Johnson & Johnson.

Correspondence should be addressed to: Harpal S. Khanuja, MD, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation & Replacement, Sinai Hospital of Baltimore, 2401 W Belvedere Ave, Baltimore, MD 21215 (paulkhanuja@gmail.com).

Abstract

Short-stem total hip arthroplasty has been proposed as a bone-conserving procedure for the younger and more active population undergoing total hip arthroplasty. Although various short stems are currently available, no studies compare the outcomes between these stems. The aim of the current study was to conduct a systematic review of the clinical and radiographic outcomes of the various short stems that have been approved for use in the United States by the Food and Drug Administration. Outcomes that were assessed included implant survivorship, Harris Hip scores, thigh pain, periprosthetic fracture, subsidence, proximal stress shielding, and the prevalence of stem malalignment and inappropriate implant sizing.

The authors are from the Rubin Institute for Advanced Orthopedics (SB, RP, KI, MAM, HSK), Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland; and the Department of Orthopaedic Surgery (SFH), Beth Israel Medical Center, New York, New York.

Drs Banerjee, Pivec, and Issa have no relevant financial relationships to disclose. Dr Harwin receives royalties from Stryker and SLACK Incorporated; is on Speaker’s Bureau for Stryker and Convatec; is a paid consultant for Stryker and Convatec; has stock or stock options in Stryker; and is on the editorial or governing board for the Journal of Arthroplasty, Orthopedics, Journal of Knee Surgery, and Surgical Technology International. Dr Mont receives royalties from Stryker and Wright Medical Technology, Inc; is a paid consultant for Biocomposites and TissueGene; and has received research support from DJ Orthopaedics. Dr Khanuja is a paid consultant for Ethicon and Johnson & Johnson.

Correspondence should be addressed to: Harpal S. Khanuja, MD, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation & Replacement, Sinai Hospital of Baltimore, 2401 W Belvedere Ave, Baltimore, MD 21215 (paulkhanuja@gmail.com).

Cementless total hip arthroplasty (THA) has become the standard fixation option in the United States and is used in more than 90% of all THAs.1,2 This method of fixation offers biologic bone ingrowth with the potential for the bone-implant interface to remodel and has resulted in excellent outcomes even with expanded indications, which include younger, more active patients.3,4 However, despite the success observed with these components, several concerns, including thigh pain and proximal stress shielding, have been raised, particularly with stems that have primarily diaphyseal fixation.5–7

The recent increase in enthusiasm for minimally invasive surgery and the desire to obtain greater bone loading proximally has led to the evolution of implants with short, conservative, or neck-preserving stems.8–12 These stems are defined as implants that achieve fixation in the femoral neck or in the proximal metaphysis. Although this is not necessarily a new design and several implants have been available in the United States and Europe for approximately 20 years, an increasing number of reports have been published recently that demonstrate that these implants are gaining in popularity as surgeons become increasingly interested in tissue- and bone-sparing surgery.13–15

As stems become shorter, improved proximal loading may be offset by a decrease in the primary stability of the implant when compared with conventional stems. Primary stability with less than 20 μm of micromotion at the bone-implant interface is crucial for promoting bone rather than fibrous ingrowth for the long-term success of cementless fixation.16–18

Various studies have shown that retaining the femoral neck contributes to improved primary stability with these short-stem femoral implants.19–21 Thus, most short stems currently available aim to achieve primary stability through neck retention and the impaction of bone in the femoral neck cylinder or in the proximal femoral metaphysis. With the exception of the Mayo prosthesis (Zimmer, Inc, Warsaw, Indiana), which has been used in the United States for more than 20 years, the majority of these stems have not yet been approved for general use by the Food and Drug Administration (FDA) and have primarily been used for patients in Europe.

Furthermore, many of the newer stem designs, which have been introduced in the past 5 years in the United States, are currently in clinical trials and have few short- or mid-term follow-up data available (Table 1). Although excellent clinical results have been reported in some studies at these follow-ups, some authors have reported persistence of thigh pain, stem migration, aseptic loosening, and proximal stress shielding with some of the designs.22–24 Others have reported increased stem malalignment and a higher rate of intraoperative fractures, which may temper their widespread use.25

Short Stems Currently FDA Approved for Use in the United States

Table 1: Short Stems Currently FDA Approved for Use in the United States

Multiple studies have reported outcomes of individual short stems in THA, but few reports have analyzed these implants as a single group. The purpose of the current study was to systematically review the literature and analyze the outcomes of FDA-approved short stems. Specific outcomes evaluated were implant survivorship, Harris Hip scores, thigh pain, periprosthetic fractures, subsidence, proximal stress shielding, and the prevalence of stem malalignment and implant over- or undersizing.

Materials and Methods

A literature search was performed using the electronic medical databases PubMed, CINAHL Plus, EMBASE, and SCOPUS to identify all articles reporting the outcomes of short or conservative femoral stems in THA. Short stems were defined as those having fixation in the neck or in the proximal femoral metaphysis. The following terms were used to search the databases: short, conservative, metaphyseal, neck, sparing, stem*, and hip arthroplasty. The names of the individual prostheses were also searched. Reference lists from all retrieved manuscripts were explored to find reports that were not included in the initial search.

Inclusion criteria included all short stems that are currently approved for use in the United States and have published data. All English-language abstracts and manuscripts were reviewed. Studies reporting the clinical outcomes of hip resurfacing implants were excluded. Studies reporting the outcomes of stems unavailable in the United States or those that are currently under investigational use or in development were not included, as well as in vitro or biomechanical studies that did not report clinical outcome metrics. If multiple reports by a single author or a group of authors composing a clinical series were found, only the most recent report was included. Single-patient case reports were reviewed but not included in the final analysis.

Initial review of the literature identified 119 articles concerning short stems. Of these, 58 reported stems that are not available in the United States or are not FDA-approved, so they were excluded from this review. A further 39 reports were either single-patient case reports or biomechanical studies that did not report clinical outcome scores and were excluded. This resulted in 22 articles for review and inclusion in the data analysis.11,12,25–44 Level of evidence assessment revealed 1 study with Level II evidence, 5 studies with Level III evidence, and 16 studies with Level IV evidence. The studies included 2734 hips in 2277 patients (mean age, 59 years; range, 36–79 years) available for analysis at a mean follow-up of 4 years (range, 0.6–9.8 years). Data gathered from the individual studies were subcategorized for the Mayo stem (n=10), lateral flare design (n=6), and shortened proximally coated stem (n=6) to assess and compare the outcomes of these 3 stem designs because they have the maximum available clinical data.

Demographic, clinical, radiographic, and survivorship data were extracted from each study and analyzed to find the pooled mean for each category. Functional outcomes were analyzed on the basis of physician-based objective outcome measures, which included Harris Hip and Merle D’Aubigne scores. Implant survivorship data were substratified based on the mean survivorship at less than 2 years, between 2 years and 5 years, and more than 5 years. The incidences of aseptic loosening and osteolysis were also assessed. Complications included the frequency of periprosthetic fractures and the incidence of thigh pain. Evaluation of the reported radiographic outcomes was assessed for stem migration, malalignment, and stem over-or undersizing.

All data were extracted and incorporated into an Excel spreadsheet (Microsoft Corporation, Redmond, Washington). For each of the 3 stem types, the metrics from the individual studies were pooled to obtain a mean value for the entire group of studies. Because all of the studies except 1 in this review did not provide comparison groups with other standard stem designs,40 statistical analysis of the data to determine whether outcomes between short stems and traditional stem designs were significantly different was not possible.

Results

Overall mean stem survivorship for all short stems was 99.5% (range, 97.5%–100%) at a mean follow-up of 3.9 years (Table 2). Mean stem survivorship at less than 2-year follow-up was 99.4% (range, 98.2%–100%). At 2- to 5-year follow-up, mean stem survivorship was 99.6% (range, 97.5%–100%), and this was maintained at more than 5-year follow-up (mean, 99.6%; range, 98.2%–100%). Mean stem survivorship for the Mayo prosthesis was 99.2% (range, 97.5%–100%) at a mean follow-up of 4.9 years, whereas the lateral flare-type prosthesis and shortened proximally coated stem prosthesis had a mean stem survivorship of 99.9% (range, 99.7%–100%) at a mean follow-up of 2 years and 99.5% (range, 98.9%–100%) at mean follow-up of 4.6 years. However, when loosening or osteolysis was taken as an endpoint, the survivorship of the Mayo stem decreased to a mean of 97.5% (range, 91%–100%) at a mean follow up of 4.6 years.

Demographic Data and Implant Survivorship for Various Short-stem Designs

Table 2: Demographic Data and Implant Survivorship for Various Short-stem Designs

Mean postoperative Harris Hip score at final follow-up was 91 points (range, 83–96 points) among all stem designs. Mean postoperative score for the Mayo stem was 93 points (range, 90.4–96 points) at final follow-up. The stems with a lateral flare design and the shortened versions of the conventional stems each had a mean postoperative Harris Hip score of 90 points (range, 83–95 points).

Mean incidence of periprosthetic fracture across all short stems was 1.4% (range, 0%–7%) (Table 3). The Mayo stem had a mean periprosthetic fracture rate of 4.2% (range, 0%–7%). The stems with a lateral flare design and the shortened proximally coated stems had a mean periprosthetic fracture rate of 2.4% (range, 1.1%–5.7%) and 0.8% (range, 0%–2.1%), respectively.

Demographic Data and Implant Survivorship for Various Short-stem Designs

Table 3: Demographic Data and Implant Survivorship for Various Short-stem Designs

Mean incidence of thigh pain for the entire range of short stems was 0.4% (range, 0%–2.7%) (Table 3). The Mayo stem had a mean thigh pain incidence of 1.2% (range, 0%–2.7%). Studies on the shortened proximally coated stem had a similar incidence of thigh pain, with a mean occurrence of 1% at final follow-up. However, no incidence of thigh pain was reported at follow-ups for the stems having a lateral flare design. One study noted that 9% of patients reported persisting discomfort over the greater trochanter but had no classic symptoms of thigh pain.26

Subsidence was rarely observed with short stems, with a reported mean incidence of 1.4% (range, 0%–7%) (Table 3). Subdivision of the data showed that the Mayo stems subsided more than average (mean, 3.3%; range, 2%–7%). Stem subsidence was lower with lateral flare (0.1%) and shortened proximally coated stem (0.6%) designs; however, subsidence was evaluated in only 1 study for each of these stems.26,41 Mean incidence of proximal stress shielding with short stems was 5% across all studies. Three studies with the Mayo stem report a 5.6% incidence of proximal stress shielding (range, 4%–6%).25,27,36 Five of 6 studies of lateral flare designs noted stress shielding in all patients included in the series.12,26,30,32,40 One of 6 studies on short proximally coated stems reported absence of proximal stress shielding at short-term follow-up of 2.7 years, whereas the remaining study did not comment on bone resorption.42

Mean coronal malalignment, which was defined in all studies as greater than 5° of varus or valgus, was 20.4% (range, 5.4%–68.2%) for all stems. Only 1 study reported on the incidence of varus or valgus outliers with the Mayo stems, which was observed to be 68%.25 More studies using lateral flare designs reported coronal malalignment, with a mean incidence of malalignment of 14.2% (range, 5%–32.3%) based on 6 studies.12,26,30–32,40 Only 1 study reported this radiographic evaluation for shortened proximally coated stems, which noted that 9.9% were coronally malaligned; however, no clinical relevance was noted related to the malalignment.41

Incorrect stem sizing was not reported in any studies with the Mayo prosthesis; however, these studies did not evaluate this as an outcome measure. Three studies of lateral flare designs reported a highly variable rate of inappropriate component sizing (mean, 36.6%; range, 5.1%–81%).12,26,30 None of the studies on shortened proximally coated stems reported the incidence of incorrect stem sizing.

Discussion

Total hip arthroplasty using short stems has generated increasing interest among orthopedic surgeons, particularly in the past 5 years as more implant designs have become available (Table 1). Authors have noted that both proximally and distally fixed stems may have proximal femoral stress shielding and thigh pain.7,45–47 Although the biomechanical principles and the design rationale underlying these stems may differ, finite element analysis studies have shown that, irrespective of the design principles, short stems appear to load the proximal femur more physiologically compared with conventional stems.48,49

Combined with the trend toward THA in younger and more active patients, these newer stem designs have also helped address the perceived need for a proximal bone–conserving option to reduce bone loss as a long-term clinical problem. Moreover, these short stems have the additional advantage of easier insertion when using minimally invasive approaches for THA.10–12,50 Although these stems have been used for more than a decade, few studies have compared the overall clinical and functional outcomes of these stems or of the various short- or conservative-stem designs that are available. For this reason, the current authors performed a systematic review of the clinical and radiographic outcomes of short stems in THA for the treatment of degenerative joint diseases.

This study has several limitations. Overall, few high-quality studies were found, and the majority of studies reported Level IV evidence. Most studies had small sample sizes (fewer than 50 hips) and no conventional stem comparison group and did not consistently report objective clinical outcomes scores. The quality of the pooled data was also dependent on the homogeneity of the study populations presented in the original study. Moreover, the indications for THA were not the same in all studies. Some reports had a greater proportion of patients with rheumatoid arthritis, osteonecrosis, or other diseases, which may have introduced study population heterogeneity and bias. Furthermore, the effect of different stem geometries and the different biomechanical principles of fixation may also lead to different outcomes; therefore, it may not be completely appropriate to include all of these stems in a broad short-stem category. Despite these limitations, the current study was able to evaluate more than 2500 hips and analyze short- to mid-term clinical outcomes and implant survivorship.

Overall, implant survivor-ship at early and mid-term follow-up with failure due to aseptic loosening as an endpoint was excellent. At less than 2-year follow-up (ie, short-term), survivorship was 99%, and this was maintained at more than 5-year follow-up (ie, mid-term), which is comparable with what has been reported for conventional stems in the literature.11,27–30 It is noteworthy that most clinical data available in the literature are on the Mayo stem, which has been available for more than 20 years.

The incidence of reported aseptic loosening with the Mayo stems appears to be low (less than 2%) at short-term follow-up. Interestingly, none of the stems with a lateral flare design or the shortened proximally coated stems had reported aseptic loosening at short-term follow-up (mean, 2.4 years). The overall functional outcomes using the Harris Hip scores for assessment appear similar across the various stem designs. The current study shows that the incidence of thigh pain appears to be low with the use of short stems (less than 3%) in comparison with conventional stems, which are reported to be as high as 10% to 20%.51,52 Short-term follow-up evidence suggests that some of the newer stem designs with an extended lateral flare can potentially eliminate thigh pain as a complication.26,30–32

The incidence of periprosthetic fractures varied among the different stems designs. The Mayo and lateral flare designs have a higher incidence of periprosthetic fractures compared with shortened proximally coated stems. This could be related to the relative ease of insertion of the shortened proximally coated stems compared with the other designs. The surgical technique for insertion of some of these short stems appears to be challenging due to the system of curved awls and rasps in contrast to the straight instruments used for insertion of conventional stems. However, the curved instruments are beneficial for preparing the femoral canal in a minimally invasive fashion.

Another reason for the higher intraoperative fracture incidence, particularly for the Mayo stem, may be the use of the proximal lateral femoral cortex as a guide during insertion. This critical step requires careful broaching to avoid cortical penetration of the lateral femoral cortex, especially when poor bone quality is encountered. This may explain the higher reported incidence of periprosthetic fractures with the Mayo stem in some series.25,27,33

Stem malalignment has been found to vary markedly. The Mayo and lateral flare designs have a seemingly higher incidence of malalignment compared with shortened proximally coated stems. Currently, limited data are available regarding the incidence of stem malalignment with short stems. The unusual insertion angle of 20° to 30° varus for introduction of broaches and rasps using the round-the-corner technique has a steep learning curve to avoid stem malalignment. Stem malalignment has been associated with poor functional outcomes with conventional cemented stems, despite the fact that these stems are limited in the amount of varus/valgus malposition due to the presence of the diaphyseal component.53,54 However, the effect of malalignment on the outcomes of cementless conventional stems remains controversial and is likely related to the stem design and geometry.55 Some authors have reported instability secondary to improper seating,56,57 whereas others have reported no adverse effects from coronal malalignment.44 Long-term follow-up studies are needed to assess the effect of stem malposition on functional outcomes and survivorship for these short-stem designs.

Despite the proposed advantage of proximal load distribution with short stems, literature evidence suggests that grade 1 or 2 bone resorption, as defined by Engh et al58 can be expected with some of these stems designs.12,26,30,59 However, no reported long-term follow-up studies exist, so the clinical significance of these findings is unknown. Generally, the Mayo stems have shown a higher incidence of stem subsidence when compared with lateral flare designs and shortened proximally coated stems (mean, 3% and less than 1%, respectively).

Incorrect stem sizing has also been reported with some of the short stems with a lateral flare design. Insufficient data are available on the Mayo and shortened proximally coated stems with regard to stem sizing to draw any conclusions. Stem undersizing could be secondary to inadvertent varus stem malalignment, which was done to reduce the risk of intraoperative fracture.

Conclusion

Short stems have shown promise with excellent short-term survivorship; however, the surgical technique for insertion of these stems may be technically demanding. Insertion of these stems requires an exacting technique to avoid the potential pitfalls of malalignment, incorrect stem sizing, and intraoperative fracture. Proximal stress shielding has been reported to some extent with all short-stem designs. Mid-term survivorship data for these short stems has thus far been comparable with those for traditional stems.

Multiple stem designs are currently undergoing clinical trials, and the coming years will likely see an increase the number of stems available commercially, which emphasizes the need to evaluate the clinical outcomes of these stems at long-term follow-up. However, it is important to realize that the broad term short stems is inherently misleading because the multiple stem designs currently available differ in their morphological, biomechanical, and tribological principles. Due to these differences, a classification system categorizing these stems may help differentiate the various designs and improve future reporting of clinical and functional outcomes based on stems of similar design and principle.

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Short Stems Currently FDA Approved for Use in the United States

Stem DesignManufacturerImplant NameYear Introduced
MayoZimmer, Inc, Warsaw, IndianaMayo1984
Short proximally coatedZimmer, IncFitmore1999
Short proximally coatedStryker, Mahwah, New JerseyCitation2000
Lateral flare designDePuy Orthopaedics, Inc, Warsaw, IndianaProxima2006
Short proximally coatedBiomet, Inc, Warsaw, IndianaTaperloc Microplasty2007
Short proximally coatedBiomet, IncBalance Microplasty2007
Short proximally coatedCorin, Group PLC, Cirencester, United KingdomMiniHipa2009
Short proximally coatedSmith & Nephew, Inc, Memphis, TennesseeSMFa2011
Short proximally coatedOMNI Life Science, Inc, East Taunton, MassachusettsApex ARCa2011

Demographic Data and Implant Survivorship for Various Short-stem Designs

StudyLevel of EvidenceNo. of HipsNo. of PatientsMean Age, yMean Follow-up, yMean Harris Hip Score, pointsSurvivorship, %
Mayo stem
  Zeh et al34III2121457.993.5100
  Cruz-Vazquez et al33IV4239525NR100
  Gilbert et al25IV494257.83.119.4aNR
  Gagala & Mazurkiewicz35IV383551296100
  Goebel & Schultz36IV302657.46.816b100
  Hagel et al37IV270NRNRNR93.698.2
  Hube et al38III4545591NR100
  Falez et al28IV16014063.44.7NR97.5
  Tadeusz et al39IV343232.77NRNR
  Morrey et al27IV15914650.86.590.498.2
Lateral flare designs
  Kim et al26II707074.94.185.7100
  Kim & Oh 40III256230655.69399.7
  Kim et al32IV848478.94.689100
  Santori & Santori30IV129109519.895100
  Toth et al31IV4141492.288100
  Ghera & Pavan12IV656570.11.791100
Shortened proximally coated stems
  Patel et al41III160149752.990.5100
  Molli et al29III269246632.583.199.6
  Lombardi et al11IV64059162.70.6NR99.1
  Stulberg & Dolan 42IV6560562.793100
  Finn43,cIV141362192100
  Emerson et al44,cIV939371193.198.9

Demographic Data and Implant Survivorship for Various Short-stem Designs

Author%

ALPFDislocationThigh PainMalInappropriate SSNeck ResStem Sub
Mayo stem
  Zeh et al34NRNRNRNRNRNRNR0
  Cruz-Vazquez et al3307.12.32.7NRNRNRNR
  Gilbert et al252.04.12.02.068.2NR4.12.0
  Goebel & Schultz3603.30NRNR3.36.6a3.3
  Gagala & Mazurkiewicz 35NRNR2.6NRNRNRNR2.6
  Falez et al281.24.4 (3.8 b)NRNRNRNRNRNR
  Hagel et al371.9NRNRNRNRNRNRNR
  Hube et al3800NR0NRNRNRNR
  Tadeusz et al39NRNRNRNRNRNRNRNR
  Morrey et al277.56.2bNR0NRNR6%7
Lateral flare designs
  Kim et al260NR0.705.45.1Grade 1c0.7
  Kim & Oh4002.8 (1.4 b)1.40 (9d)7NRGrade 1cNR
  Kim et al3201.11.105NRGrade 1cNR
  Santori & Santori3005.7b1.501123.18.5NR
  Toth et al3102.4b2.4NR24.3NRNRNR
  Ghera & Pavan1201.50032.381.5Grade 1 (75%)c; Grade 2 (25%)cNR
Shortened proximally coated stems
  Patel et al4100.6bNR09.9NRNR0.6
  Molli et al2900.4NRNRNRNRNRNR
  Emerson et al 44,e02.1NR2.1NRNRNRNR
  Lombardi et al11NR1.1NRNRNRNRNRNR
  Stulberg & Dolan42003.1NRNRNR0NR
  Finn43,e007.10NRNRNRNR

10.3928/01477447-20130821-06

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