Midterm results of short-stem total hip arthroplasty

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In Part 1 of this series of articles we have discussed the main biomechanical advantages of a short stem over a standard stem in total hip arthroplasty (THA). Based on the biomechanical evidence, short stems should provide reasonable primary stability and potentially reduce stress shielding. How have the short stems performed clinically so far? In this article, Martin Buttaro, chief orthopedic surgeon at the Hospital Italiano de Buenos Aires, Argentina, reviews for us the midterm (ie, 4–10 years) clinical results—more specifically, the midterm implant survival, bone remodeling, and functional and patient outcomes.

Martin Buttaro

Italian Hospital Buenos Aires, Argentina

A classification of short stems is still elusive

Although short stems have been described as stems that are shorter than 120 mm [1], some have argued that they should not be defined by a simple length limit and that the design features should be taken into consideration as well [2–4]. Over the past two decades, a large number of short stems have been launched (and many have since been taken off the market), and a clear classification system would be useful for comparing their performance and helpful in their selection of an appropriate implant.

As has been reviewed by Y-H Kim [5], many have tried to classify short stems based on different considerations (see Table 1 for a nonexhaustive summary).

Table 1. Classification systems for short femoral stems [5]. Table reproduced under the terms of the Creative Commons Attribution Non-Commercial License. (https://creativecommons.org/licenses/by/4.0/) Source; Kim Y-H. Ultra-Short Bone Conserving Cementless Femoral Stem. Hip Pelvis. 2021 12/;33(4):181–189.

Due to the many potential design features (such as the length, shape, neck resection location, loading principle, and fixation principle) to be considered in a classification system, the definition of a short stem is still not settled, and so far, none of the systems have achieved universal usage. Currently, the Khanuja [6] and the Falez [2] systems are the more commonly cited ones.

 

Implant survival: data from a German registry

Short-stem THA has been gaining popularity; the German Arthroplasty Registry (EPRD) reported that more than 10% of all primary THAs have been performed using short stems [4].

In assessing the performance of short stems according to the EPRD records, Steinbrück et al extracted data from 266,702 primary THAs conducted between November 1, 2012 and September 30, 2019. After selecting data sets with complete follow-up from clinics with information about their case load, 17,526 primary short-stem THAs were selected for further analyses. In the analyses, the authors stratified the data for four most frequently used short stems. As shown in Table 2, among these four stems, the 5-year cumulative probability of revision (CPR) for the Optimys stems was 1.8%—better than the Metha (3.7%) and the Nanos (3.1%) stems. The authors nevertheless cautioned the readers that, in the clinics where the short stems were used and the data were extracted from, the Optimys stems were more frequently used (40% of all THAs) than the Metha and the Nanos stems (15% and 26% of all THAs, respectively), therefore an "expertise bias" is possible [4].

Table 2. Crude cumulative probability of revision of the most frequently (n ≥ 2,000) implanted short stems [4]. CPR, cumulative probability of revision; CI, confidence interval. Table reproduced under the terms of the Creative Commons Attribution 4.0 International License. http://creativecommons.org/licenses/by/4.0/ Source: Steinbrück A, Grimberg AW, Elliott J, et al. Short versus conventional stem in cementless total hip arthroplasty: An evidence-based approach with registry data of mid-term survival. Orthopade. 2021 Apr;50(4):296–305.

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  • Overall midterm implant survival of 97% or greater
  • Subsidence and migration
  • Stress shielding: a comparison of different short stems
  • Midterm results on stress shielding and bone remodeling
  • Clinical outcomes: function and pain
  • What do the midterm results tell us about short-stem total hip arthroplasty?

Part 1 | Biomechanical advantages of a short hip stem

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Part 3 | Conventional versus short stem

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Martin Buttaro

Italian Hospital Buenos Aires, Argentina

Marco Ezechieli

Vincenz Group Paderborn, St Josefs Hospital Salzkotten, Germany

Carlos Martin Lucero

Italian Hospital Buenos Aires, Argentina

This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.

References

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  3. Buttaro MA, Slullitel PA, Oñativia JI, et al. 4- to 8-year complication analysis of 2 'partial collum' femoral stems in primary THA. Hip Int. 2021 Jan;31(1):75-82.
  4. Steinbrück A, Grimberg AW, Elliott J, et al. Short versus conventional stem in cementless total hip arthroplasty : An evidence-based approach with registry data of mid-term survival. Orthopade. 2021 Apr;50(4):296-305.
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